Citation
Effects of Bolus Consistency on Timing and Safety of Swallow in Parkinson's Disease

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Title:
Effects of Bolus Consistency on Timing and Safety of Swallow in Parkinson's Disease
Creator:
TROCHE, MICHELLE S. ( Author, Primary )
Copyright Date:
2008

Subjects

Subjects / Keywords:
Bones ( jstor )
Deglutition disorders ( jstor )
Liquids ( jstor )
Parkinson disease ( jstor )
Pumps ( jstor )
Quality of life ( jstor )
Swallowing ( jstor )
Tongue ( jstor )
Trajectories ( jstor )
Trajectory measurement ( jstor )

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Source Institution:
University of Florida
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University of Florida
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Copyright Michelle S. Troche. Permission granted to University of Florida to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
Embargo Date:
7/24/2006
Resource Identifier:
496801929 ( OCLC )

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Full Text












EFFECTS OF BOLUS CONSISTENCY ON TIMING AND SAFETY OF SWALLOW
IN PARKINSON' S DISEASE

















By

MICHELLE S. TROCHE


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS

UNIVERSITY OF FLORIDA


2006

































Copyright 2005

by

Michelle S. Troche















ACKNOWLEDGMENTS

There are so many people who have provided me with support and encouragement

throughout my journey thus far. I am abundantly grateful to God for placing each of

those people in my path.

I would especially like to thank my parents who have supported me in everything I

have done until now. It is their love, guidance, and wisdom that have molded me into the

person I am today. I must also thank my brother, Joshua, who not only provided his

expert trajectory measurement skills to this project, but also keeps me grounded and sane

on a daily basis.

It is with much gratitude that I also thank my committee for their mentorship and

guidance throughout this experience. I thank Dr. Christine Sapienza for providing me

with so many amazing professional and educationally enriching opportunities throughout

the four years I have been under her mentorship. Under her guidance, I have not only

grown as a researcher, student, and clinician, but also as an individual. I thank Dr.

Rosenbek whose undying passion for all aspects of speech-language pathology (i.e.,

patient care, education, research) is truly inspirational. His example of using just the

right amount of "brains" and just the right amount of "heart" in the care of patients is one

I hope to follow.

Lastly, I would like to thank my classmates, labmates, and friends, especially

Christina del Toro, whose enthusiasm and motivation were essential for the completion









of this project and Karen Wheeler, who always made herself available to help, be it with

statistics, answering questions, or just listening to my theories. Many thanks to all.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iii

LIST OF TA BLE S .............. ............ ... ........... .. ........... .............. .. vii

LIST OF FIGURES ............. .. ..... ...... ........ ....... .......................... viii

A B ST R A C T ................. .......................................................................................... x

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

B a ck g ro u n d ............................................................................................ ....... ..... .
Significance and H ypotheses ............................................................... ............... 12

2 M ETHOD S ..................................... ................................. ........... 14

P participants ................................ .................. ...... ............ .... ........ 14
Clinical Assessment of Parkinson's Disease Severity..............................................15
Videoradiography ............. .... ............. .................... .. .......... .......... 16
Data Analysis ..................................................... 18
M easurem ents Related to Sw allow Tim ing.................................. .................... 18
Measurements Related to Penetration/Aspiration ................... .............. 19
M easurem ents of Hyoid M otion........................... .................... ............... 20
M measures of Quality of Life ...... ............................................... ............... 21
S statistic s .......................................................................... 2 2
P rim ary A im ................................................................2 2
Exploratory Study ......................................................... .. ......22

3 R E S U L T S .............................................................................2 3

P rim a ry A im ............................................................................................................... 2 3
R e liab ility ................................................................2 4
Statistical A naly sis ...........................................................24
Exploratory Study: Hyoid Trajectory Measurements ..............................................28
R e liab ility ................................................................2 8
Statistical A naly sis ...........................................................2 8
Case Studies................... ......... .. .... .... .............. ...30



v









4 D ISC U S SIO N ............................................................................... 39

Prim ary A im .......................................39
M measures of B olus Transit........................................................ ............... 39
Measures of Penetration/Aspiration .............. ..............................................42
Q quality of Life .............................................................................. 43
Exploratory Study ............... ................. ......................... ............ 44
Lim stations and Strengths ........................................................................... 47
Im plications for Future R esearch.......................................... ........... ............... 48
Implications for Swallow Intervention ........... ................................. ...............48

APPENDIX

A UNIFIED PARKINSON'S DISEASE RATING SCALE (UPDRS).......................50

B TH E SW A L -Q O L SU R V EY ........................................................... .....................56

B IO G R A PH IC A L SK E TCH ..................................................................... ..................74
















LIST OF TABLES

Table pge

2-1 Participant D em graphics ............................................... ............................. 15

2-2 H oehn and Y ahr Scale........................................... ....................................... 16

2-3 Tags of bolus oral and pharyngeal transit times.....................................................18

2-4 Penetration-A spiration Scale......................................................... ............... 19

3-1 Mean values for the dependent variables. ..................................... ............... 23

3-2 Pearson r correlation results for inter-rater reliability...........................................24

3-3 R results of the M A N O V A .......................................................................... ... .... 25

3-4 Results of the one-way analysis of variance (ANOVA). .......................................25

3-5 Means and standard deviations for dependent variables as a function of bolus
consistency. .......................................... ............................ 26

3-6 Results of Pearson r correlations within the thin consistency..............................27

3-7 Results of Pearson r correlations within the thick consistency. .............................27

3-8. Intra-rater reliability for trajectory measurements.................................................28

3-9 Inter-rater reliability for trajectory measurements ................................................28

3-10 Means and standard deviations of dependent measures as a function of bolus
consistency. .......................................... ............................ 28

3-11 Order of swallow events and hyoid trajectory measurements for "safe swallow"...30

3-12 Order of swallow events and hyoid trajectory measurements for "unsafe
sw allow .................................................................................. 3 1

3-13 Order of swallow events and hyoid trajectory measurements for shorter swallow..34

3-14 Order of swallow events and hyoid trajectory measurements for longer swallow. .35
















LIST OF FIGURES


Figure pge

2-1 Example of fluoroscopic image from where the measurements were completed.... 17

2-2 Figure depicting the reference line drawn from C3 to the hyoid prominence in
frame one and a second line from a later frame ................... ................... .......... 21

3-1 Figure depicting the change in average and max angle as a function of bolus
consistency. .......................................... ............................ 29

3-2 Figure depicting the change in average and max displacement as a function of
b olu s con sisten cy ............................................................................ ............... 2 9

3-3 Figure depicting the change in average and max velocity as a function of bolus
consistency. .......................................... ............................ 30

3-4 Figure depicting the angle of the hyoid in degrees and the relationship to the
defined swallow events in the "safe swallow" ......... .......................... ........ ....... 31

3-5 Figure depicting the angle of the hyoid in degrees and the relationship to the
defined swallow events in the "unsafe swallow" .............................................. 32

3-6 Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the "safe swallow" ..........................32

3-7 Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the "unsafe swallow" ......................33

3-8 Figure depicting the hyoid trajectory in the "safe swallow".......... ..................33

3-9 Figure depicting the hyoid trajectory in the "unsafe swallow".............................34

3-10 Figure depicting the angle of the hyoid movement and the relationship to the
defined swallow events in the shorter swallow ............................... .... ........... 35

3-11 Figure depicting the angle of the hyoid movement and the relationship to the
defined swallow events in the longer swallow .............................. ............... 36

3-12 Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the shorter swallow..........................36









3-13 Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the longer swallow...........................37

3-14 Figure depicting the hyoid trajectory in the shorter swallow................................37

3-15 Figure depicting the hyoid trajectory in the longer swallow................................38















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts

EFFECTS OF BOLUS CONSISTENCY ON TIMING AND SAFETY OF SWALLOW
IN PARKINSON' S DISEASE

By

Michelle S. Troche

May 2006

Chair: Christine Sapienza
Major Department: Communication Sciences and Disorders

Safety and timing of swallow are essential for health and quality of life. The study

of swallow in Parkinson's disease (PD) is especially important, in that aspiration

pneumonia is the leading cause of death in this population. One of the therapeutic

strategies employed in the treatment of swallowing problems is diet modification. The

primary aim of this study was to investigate the effects of bolus consistency on P-A score

and timing of the oral-pharyngeal swallow of persons with PD. The secondary goal was

to explore the relationship between various quantifiable components of hyoid movement

and measures of swallow timing and penetration/aspiration. The videoradiographic

images of ten participants with PD swallowing six thin, and six pudding thick boluses

were measured. The results demonstrated various significant differences and

relationships among the dependent variables (i.e., oral transit time, pharyngeal transit

time, number of tongue pumps, P-A score, and SWAL-QOL measures). The implications

for further research and clinical practice are discussed.














CHAPTER 1
INTRODUCTION

Background

Parkinson's disease (PD) is a neurologic condition characterized by impairment of

the basal ganglia with death of dopaminergic neurons primarily in the substantial nigra

pars compact (Brodal 1998; Marsden, 1984). Cardinal symptoms include skeletal

muscle rigidity, akinesia (inability to initiate movement), hypokinesia (reduced range of

movement with consequent target undershooting), bradykinesia (slowness of movements

once initiated), and resting tremor (Brodal, 1998; Hoehn & Yahr, 1967; Marsden, 1989).

The above mentioned physiological changes affect the various muscle systems and cause

changes at different levels of function. Of particular importance to this study, is the

presence of changes in the bulbar system.

One of the primary bulbar changes reported by patients with PD is speech

impairment. The speech of persons with PD, termed hypokinetic dysarthria, has been

studied to great extent (i.e., Darley, Aronson, & Brown, 1969a; 1969b; Canter, 1963,

1965a, b). Although persons with hypokinetic dysarthria do not comprise a homogenous

group, there are several predominant features affecting many domains of speech

including respiration, phonation, articulation, resonance, and prosody (Darley et al.,

1969a; 1969b). More specifically, speech associated with PD has been described as

slurred (Doshay, 1960) and has been characterized by monopitch, reduced stress,

monoloudness, imprecise consonants, variable rate, inappropriate pauses, short rushes,

and a harsh, breathy voice (Darley et al., 1969a, b; Canter, 1963, 1965a, b).









Along with these predominant speech characteristics, James Parkinson (1817) also

reported changes in swallow function associated with the disease. In his first published

description of PD, An Essay on the \haikiing Palsy, he reported prepharyngeal

abnormalities of ingestion, including difficulty initiating the swallow, maintaining self-

feeding, impaired oral containment of both saliva and food, and labored lingual

movements. His observations have proven quite accurate, but since Parkinson's essay,

much more research has been conducted in the area of normal swallowing function and

swallowing dysfunction in various populations, including PD (i.e., Ardran & Kemp,

1951; 1956; 1967; Blonsky, Logemann, Boshes, & Fisher, 1975, Bosma, 1957;

Logemann, 1983).

Swallowing is a complex process consisting of various pressure changes which

successfully transport a bolus from the oral cavity to the esophagus and into the stomach.

The healthy swallow consists of four main phases: (1) the oral-preparatory phase, in

which food is manipulated in the oral cavity; (2) the oral phase, at which time the tongue

propels the bolus to the posterior aspect of the mouth and the swallow is triggered; (3) the

pharyngeal phase, where the swallow is triggered and the bolus is transported through the

pharynx, and (4) the esophageal phase at which time peristalsis transports the bolus

through the esophagus and into the stomach (Logemann, 1983).

The different phases of swallow are controlled by various neural substrates. The

oral-preparatory phase, which is considered to be volitionally controlled, is mediated by

such cerebral structures as the cingulated cortex, insula, inferior frontal gyms,

supplementary motor area, sensorimotor cortex, supplementary sensory area, premotor

cortex, antereolateral and posterior parietal cortex, basal ganglia, thalamus, and









cerebellum (Hamdy et al., 1996; Hamdy, Mikulis, Crawley, et al., 1999; Hamdy,

Rothwell, Brooks, et al., 1999; Hamdy, Xue, Valdez, & Diamant, 2001; Martin,

Goodyear, Gati, & Menon, 2001; Martin & Sessle, 1993; Mosier et al., 1999; Zald &

Pardo, 1999). Alternatively, it has been suggested that the pharyngeal phase of swallow,

which is mainly considered reflexive, is cortically controlled by indirect pathways

between extrapyramidal cortical motor planning regions and lower motor neurons

(Huckabee, Deecke, Cannito, Gould, & Mayr, 2003).

Persons with PD may experience changes in all the phases of swallow. It is

uncertain which phase of the swallow is most impaired with the disease and what

mechanisms are largely responsible for aspiration. Ali et al. (1996) stated that the

majority of patients with PD have dysphagia related to the oral-pharyngeal phase of

swallow, calling pharyngeal bolus transfer a "major determinant" of dysphagia in this

population. Bassotti, Germani, Pagliaricci, Plesa, & Giuletti (1998), on the other hand,

reported that esophageal motility was the most affected of the swallowing functions.

Interestingly, the vast majority of these studies have been conducted utilizing only one

consistency of bolus, which is difficult to generalize to the patients' routine eating habits.

More specifically, the study of swallow function in those with PD indicates

changes to the oral phase of swallow relating to bolus preparation and also indicate the

presence of labial bolus leakage, deficient or hesitant mastication, impaired lingual

motility, lingual tremor, and slowed and limited mandibular excursion, all of which affect

the overall formation of the bolus (Ertekin et al., 2002: Leopold & Kagel, 1996). Oral

transit time is also often slowed in PD with changes including slow, repetitive lingual

pumping, inability to properly propel the bolus posteriorly, prolonged lingual elevation,









hesitancy in initiating the swallow, preswallow spill, and piecemeal deglutition (Blonsky

et al., 1975; Born, Harned, Rikkers, Pfeiffer, & Quigley, 1996; Coates& Bakheit, 1997;

Ertekin et al., 2002: Leopold & Kagel, 1996). Consequently, post swallow residue in the

oral cavity is often observed (Ali et al., 1996; Nagaya, Kachi, Yamada, & Igata, 1998;

Stroudley & Walsh, 1991).

Many changes also occur in the pharyngeal phase of swallow. Pharyngeal transit

time is reported to be slow due to various symptoms causing dysfunction in the

pharyngeal phase. Some of these changes include abnormal or delayed contraction of the

pharyngeal wall with subsequent coating of the walls (Ali et al., 1996), deficient

epiglottic positioning, decreased epiglottic range of motion, stasis in the valleculae and/or

pyriform sinuses (Blonsky et al., 1975; Ertekin et al., 2002; Leopold & Kagel, 1997),

slow laryngeal elevation and excursion, aspiration, UES incoordination, as well as

cricopharyngeal dysfunction (Ali et al., 1996; Born et al., 1996; Bushmann, Dobmeyer,

Leeker, & Perlmutter, 1989; Coates & Bakheit, 1997; Eadie & Tyrer, 1964).

Finally, changes in esophageal function which lead to prolonged transit times

include decreased peristaltic motion, especially in the inferior third of the esophagus

(Blonsky et al., 1975; Born et al., 1996), and delayed opening of the LES leading to

gastro-esophageal reflux disease (Castell et al., 2001; Leopold & Kagel, 1997; Nagaya et

al., 1998; Stroudley & Walsh, 1991).

The swallow mechanism as a whole is itself composed of many structures; the

muscles of which are both of the striated and smooth type. The smooth muscle is

controlled by the autonomic nervous system and may cause changes in esophageal and

pharyngeal transit times due to motility changes evidenced by decreased peristalsis









(Athlin, Norberg, Axelsson, Moller, & Nordstrom, 1989; Lieberman et al., 1980).

Changes due to the cardinal symptoms of PD are also observed in the swallow system

with decline in motoric abilities due to rigidity, hypokinesia, and tremor; processes

controlled by dopaminergic pathways (Lieberman et al., 1980). Specifically, rigidity and

bradykinesia are likely responsible for difficulty chewing and drooling of saliva. Eadier

& Tyrer (1965) and Ertekin et al. (2002) hypothesized that the hypokinetic, reduced rate

of spontaneous swallowing movements, and the "slowness of segmented but coordinated

sequential movements" a problem seen in other motor systems in PD, may be the most

significant cause of swallow dysfunction in PD. It is interesting to note, that often times

patients with PD demonstrate greater impairment of voluntary tasks versus involuntary

tasks (Yamaguchi & Kabayashi, 1998). This is important to the understanding of

swallow dysfunction in PD due to the voluntary nature of the oral phase of swallow, and

the involuntary nature of the pharyngeal phase of swallow. In addition to the above-

mentioned mechanistic impairments, it has been reported that swallow dysfunction in PD

may be secondary to impairment of other mechanisms including autonomic processes,

perception, cognition, and emotion (Athlin et al., 1989).

Severity and degree of motor involvement in PD do not necessarily correlate with

severity of swallow dysfunction, making the timeline of swallow changes difficult to

predict (Ali et al., 1996). Similarly, clinical staging does not predict swallow difficulty

(Bushmann et al., 1989). For instance, the literature suggests that the UnifiedParkinson

Disease Rating Scale (UPDRS; Fahn, Marsden, Calne, & Goldstein, 1987), which is used

to assess severity of the disease, does not predict swallowing dysfunction. In fact, Ali et

al. (1996) found no relation between limb tremor and lingual tremor and no relation









between muscular rigidity and dysmotility of the pharyngeal wall. The poor correlation

between swallowing dysfunction and disease severity rating, along with patient

complaints of swallow problems and findings on videofluoroscopic examinations makes

swallow assessment and subsequent treatment in PD a difficult task (Bushmann et al.,

1989).

Currently the primary treatment for PD is Levodopa (L-Dopa). L-Dopa has been

found to be efficacious for the treatment of the primary clinical features of the PD

syndrome (Calne, Shaw, Spiers, & Stem, 1970). The same results have not been

observed consistently in the treatment of dysphagia in PD (Born et al., 1996; Hunter,

Crameri, Austin, Woodward, & Hughes, 1997; Leopold & Kagel, 1997). Nilson,

Ekberg, Olsson, & Hindfelt (1996) assert that oral and pharyngeal function in PD are not

the result of reduced dopamine levels, therefore L-Dopa is ineffective. On the other

hand, Bushmann et al. (1989) found less vallecular residue and decreased coating of the

pharyngeal walls post treatment with L-dopa. The strongest theory as to the

ineffectiveness of dopaminergic medications in PD swallow is the dual involvement of

muscle tissue described previously. Therefore treatment for swallow dysfunction in PD

cannot be treated solely with medical interventions, but instead by compensatory

strategies and dietary modifications.

Dysfunction in swallow, also called dysphagia, can lead to many life-threatening

problems such as dehydration, malnutrition, weight loss, aspiration of solids and liquids,

and pneumonia (Bushmann et al., 1989; Raut, McKee, & Johnston, 2001). A timely and

safe swallow, is essential to health and quality of life. Assessment of swallow safety and

treatment of swallowing disorders is an integral part of a speech-language pathologist's









scope of practice. Unfortunately, there are no clear cut guidelines regarding the amount

of aspiration which can occur in a specific patient before the patient is at severe risk for

pneumonia. Actually, physicians show variance in their tolerance for aspiration in

patients, with some tolerating only small amounts of aspiration, and others more. In

addition, of concern is whether or not the patient is healthy enough to combat a severe

infection like pneumonia; therefore, aspiration is kept to a minimum in order to avoid any

complications. Logemann (1983) suggests that health, mobility, cognition, frequency of

aspiration, and type of material aspirated all influence the body's response to aspiration

and penetration. Rosenbek, Robbins, Roecker, Coyle, & Wood (1996) suggest that the

amount of aspiration, the extent to which the material passes into the airway, and the

ability of the person to expel the material are also crucial. Logemann (1983)

recommends that any patient who aspirates at least 10% of boluses of a specific

consistency, even following use of maneuvers and compensatory strategies, should

eliminate or restrict their oral consumption of boluses of said consistency.

Currently, the most effective method of determining presence and degree of

aspiration is videoradiographic evaluation; unfortunately though, this method cannot

elucidate the amount of aspiration a person can tolerate before pneumonia develops and

possible death ensues. There are few scales which actually quantify the swallow

impairment. The Penetration-Aspiration Scale (P-A Scale; Rosenbek et al., 1996) is

currently the most reliable measure. This ordinal measurement describes whether or not

the bolus has entered the airway, the degree to which it has entered the airway, whether

there is any residue, and whether the person tried to expel the material or not.









Although it has often been considered a feature of late stage PD (Lieberman et al.,

1980), dysphagia has also been reported in early stages ofPD (Ali et al., 1996; Coates &

Bakheit, 1997; Stroudley & Walsh, 1991) and as a presenting symptom of the disease

(Croxson & Pye, 1988). These changes are of marked concern due to its association with

considerable morbidity from nutritional and pulmonary compromise (Ali et al., 1996;

Bassotti et al., 1998; Coates & Bakheit, 1997), as well as the possibility of death

(Kirshner, 1997; Stroudley & Walsh, 1991). In fact, aspiration pneumonia is the leading

cause of death in PD (Fernandez & Lapane, 2002; Gorell, Johnson, & Rybicki, 1994;

Hoehn & Yahr, 1967; Schiermier, Schafer, Schafer, Greulich, & Schlafke, 2001; Shill &

Stacy, 1998; Singer, 1992).

The incidence of dysphagia in persons with PD is hard to define, with evidence of

swallow dysfunction reported between 18.5% to 100% of the patients studied (Ali et al.,

1996; Bassotti et al., 1998; Coates & Bakheit, 1997; Hunter et al., 1997; Logemann,

Blonsky, & Boshes, 1975; Stroudley & Walsh, 1991), depending on the criteria and

instrumentation used to diagnose dysphagia and the participant population selected. In

comparison, studies assessing patients' awareness of dysphagia have found only 15-50%

of these patients demonstrating signs of swallow dysfunction complain of dysphagia,

compared to 6-12% in age matched adults (Born et al., 1996; Logemann et al., 1975).

Therefore, many patients with PD are unaware of their swallowing dysfunction. In

addition, studies have found that as many as 15% of patients with PD who do not

complain of dysphagia do not recognize they are aspirating, termed silent aspiration (Ali

et al., 1996). It is this aspiration, in conjunction with a decreased cough strength and









delayed cough reflex, which places patients with PD at significant risk for complications

related to swallow dysfunction (Ertekin et al., 2002; Hunter et al., 1997).

Swallow timing, although less critical to health than swallow safety, has significant

implications for quality of life. As described above, persons with PD often develop

dysphagia early on in the disease process with tongue pumping arising as one of the first

symptoms. This tongue pump can cause increased oral transit times and therefore

increased eating time for the patient. These changes may have social or personal

repercussions which affect the person's quality of life.

In order to aid the swallow function in patient populations, swallow therapy

strategies have been developed by clinicians. Swallowing maneuvers and other similar

compensatory strategies, although valuable in many populations, may be less beneficial

in the PD population which often has difficulties with cognition, including an inability to

maintain and shift sets, and problems with the coordination of complex tasks (i.e., Bayles,

1990; Cooper et al., 1991). This is significant because many compensatory strategies

used for swallow are often multi-step, complex motor movements. Such maneuvers

include the supraglottic swallow in which the patient is instructed to take a breath and

hold it while swallowing and then cough after the swallow, and the super-supraglottic

swallow, the instructions of which are the same as above, but the patient is instructed to

bear down while holding their breath (Martin, Logemann, Shaker, & Dodds, 1993;

Mendelsohn, & Martin, 1993; Ohmae, Logemann, Kaiser, Hanson, & Kahrilas, 1995;

Ohmae, Logemann, Kaiser, Hanson, & Kahrilas, 1996). Others include maneuvers such

as the Mendelssohn (Jacob, Kahrilas, Logemann, Shah, & Ha, 1989; Kahrilas, Dodds,

Dent, Logemann, & Shaker, 1988; Kahrilas, Logemann, Krugler, & Flanagan, 1991;









Lazarus, Logemann, & Gibbons, 1993; Logemann & Kahrilas, 1990) and Effortful

swallow (Bulow, Olsson, & Ekberg, 1999; Hind, Nicosia, Roeker, Carnes, & Robbins,

2001; Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002; Pouderoux & Kahrilas,

1995), where patients are asked to keep the larynx elevated for several seconds after the

swallow, and to swallow hard tightening the throat and neck muscles, respectively

(Logemann, 1983). The complex nature of these tasks, in conjunction with the cognitive

and working memory impairments often present, leave few options for the treatment of

swallowing disorders in persons with PD. This is of particular concern in that swallow

dysfunction can initiate in the early stages of PD, as can cognitive changes. Dietary

modifications may be most beneficial in this population.

Generalization and maintenance of maneuver and compensatory strategy use

outside of the clinic may be compromised by possible anosognosia, or unawareness of

deficits associated with illness, in patients with PD. Although little research has been

conducted in the area of anosgnosia in PD, Starkstein et al. (1996) and Seltzer,

Vasterling, Mathias, & Brennan (2001) found that patients with PD did demonstrate

some anosognosic symptoms, although not as severe as those observed in Alzheimer's

disease. Clinically, it seems that the symptoms observed in patients with PD can more

accurately be described as a problem of "insight." Often times patients with PD require

much more cueing during and before tasks in order for the tasks to be completed

accurately and appropriately, this may be a function of both working memory

dysfunction and "insight" deficits, impeding the patient from completing the tasks to their

maximum performance. It is these problems of generalization and maintenance, coupled









with the challenge of learning the often complex maneuvers, that may make this type of

swallow therapy a real challenge in this population.

Dietary modifications as a treatment strategy for oral-pharyngeal dysphagia

normally consist of thickening liquids or recommending puree consistency foods (Raut et

al., 2001). Although there is research investigating the effects of consistency on swallow

in healthy adults, healthy older adults, and persons with dysphagia caused by stroke and

other neurological conditions, consistency differences related to swallow function in PD

has not been adequately studied.

In terms of diet modification, thicker liquids have been used based on the theory

that perhaps the thickened liquid stimulates the pharynx to contract harder and longer in

order to protect the airway more adequately (Raut et al., 2001). Research involving

healthy ageing persons and others with dysphagia secondary to stroke reports results

demonstrating that as a liquid becomes more viscous duration of tongue base posterior

pharyngeal wall contact increases, oral-pharyngeal transit time increases, pharyngeal

delay times decrease, duration of peristaltic waves are longer, and average EMG activity

is increased (Ding, Logemann, Larson, & Rademaker, 2003; Kendall, Leonard, &

McKenzie, 2001; Kuhlemeier, Palmer, & Rosenberg, 2001). Increases in oral-pharyngeal

pressures and velocities are needed in order to propel the bolus into the pharynx (Hiss,

Strauss, Treole, Stuart, & Boutilier, 2004).

Research has also focused greatly on the movement of the hyoid bone during

swallowing of differing consistencies in healthy normal controls and persons with

neurological impairment (not including PD), with some controversy. Some of the

literature shows that thicker boluses can lead to greater hyoid displacements and









subsequently higher magnitudes of laryngeal movement, but shorter laryngeal elevation

durations (Dantas & Dodds, 1990; Dantas, Dodds, Massey, & Kern, 1989; Ertekin et al.,

1997), yet other researchers have found just the opposite (Bisch, Logemann, Rademaker,

Kahrilias, & Lazarus, 1994; Ekberg, Liedberg, Owall, 1986; Perlman, Vandaele, &

Otterbacker, 1995). Nonetheless, research using EMG has consistently found a positive

relationship between bolus viscosity and activation magnitude and duration of the

suprahyoid and infrahyoid muscles (Dantas & Dodds, 1990; Palmer, Luschei, Jaffe, &

McCulloch, 1999).

Significance and Hypotheses

There are many unanswered questions related to the effects of bolus consistency on

the oral and pharyngeal phases of swallow in PD. Of more concern, is the fact that these

variables have not been described in relationship to the swallow timing and

penetration/aspiration, which are both factors essential to health and quality of life in this

population which has a high incidence of dysphagia and aspiration pneumonia (often

resulting in death). To the researcher's knowledge, no well-controlled study has ever

looked at both the oral and pharyngeal phases of swallow as related to bolus consistency

in the same group of participants with PD, with special attention to swallow timing and

penetration/aspiration; a topic of great clinical significance. The primary aim of this

study is to investigate the effects of bolus consistency on the P-A score and timing of the

oral-pharyngeal swallow of persons with PD. The secondary goal of this study is to

explore the relationship between the various quantifiable components of hyoid movement

and measures of swallow timing and penetration/aspiration.

The following questions and hypotheses were developed for study:









1. What are the effects of bolus consistency on the timing of swallow in persons with
PD as measured by oral and pharyngeal transit times and number of tongue pumps?
It was hypothesized that both oral and pharyngeal transit times would increase
11 ith thicker consistencies versus thinner consistencies. It was also y Ilpolthei\i:
that oral transit time would be increased to a greater degree across the consistency
condition and that the number of tongue pumps would increase significantly i ilh
thicker consistencies.

2. What are the effects of bolus consistency on Penetration-Aspiration Scale in
persons with PD?
It was hypothesized that P-A scale values would decrease i ith thicker
consistencies, than thinner consistencies, indicating increased safety of swallow.

3. Is there a relationship between timing and penetration/aspiration within the thick
and thin consistency conditions?
It was hypothesized that there would be a significant negative correlation between
oral and pharyngeal transit times and P-A scale values for the thick and thin
consistencies.

4. Do the distinct changes evidenced in the swallow of persons with PD translate to
changes in quality of life as measured by the SWAL-QOL?
It was hypothesized that persons i/ ith more impaired oral stages of swallow would
report more impaired quality of life.














CHAPTER 2
METHODS

Participants

Ten (5 male; 5 female; mean age 68.5 years; Table 2-1) participants with idiopathic

Parkinson's disease (PD) were recruited from the University of Florida (UF) and Malcom

Randall Veterans Affairs (VA) Medical Center Movement Disorders Clinics in

Gainesville, Florida. All participants were on one or more anti-Parkinsonian

medications (i.e., Levodopa/Carbidopa, Selegeline, Amantadine etc).

Inclusionary criteria included: 1) age between 35-80 years; 2) diagnosis of

idiopathic Parkinson's disease by a movement disorders neurologist; 3) moderate clinical

disability level (II-III; Hoehn & Yahr, 1967); and 4) score of at least 24 on the Mini-

Mental State Examination (Folstein, Folstein, & McHugh, 1975).

Exclusionary criteria included: 1) other neurological disorders; 2) gastrointestinal

disease; 3) gastro-esophageal surgery; 4) head and neck cancer; 5) history of breathing

disorders or diseases; 6) untreated hypertension; 7) heart disease; 8) history of smoking in

the last five years; 9) failing the screening test of pulmonary functions; and 10) difficulty

complying due to neuropsychological dysfunction (i.e., severe depression).

Once patients were screened for inclusionary and exclusionary criteria, participants

gave written consent and were subsequently enrolled in the study. The study was

approved by the UF and VA Institutional Review Boards (154-2003). Participants were

all "on" PD medications when the testing was conducted. They were tested one-hour

after medications were taken in order to help ensure measures were completed at optimal









medication activity (Nutt, 1987). In addition, all participants reported feeling "on" their

medications, and none of the patients showed signs of dyskinesias.

Table 2-1. Participant Demographics
Participant Gender Age H & Y
No.
1 F 56 2
2 F 74 2
3 M 71 2
4 M 73 2
5 M 76 2
6 M 77 2
7 M 56 2
8 F 76 3
9 F 63 2
10 F 63 2


Clinical Assessment of Parkinson's Disease Severity

Each patient underwent a clinical assessment of Parkinson's disease severity. This

assessment was completed by a UF Movement Disorders neurologist. Severity was

measured using the Unified Parkinson's Disease Rating Scale (UPDRS; Fahn et al., 1987;

Appendix A) and Hoehn & Yahr Scale (1967; Table 2-2). The UPDRS quantifies the

primary and secondary motor symptoms of a person with PD by assessing cognition,

ability to perform activities, mentation, activities of daily living, and neurological

examination. For the purposes of this clinical assessment, only the motor exam portion

(III) of the UPDRS was utilized. The Hoehn & Yahr scale is based on five stages, and is

an objective measure used to grade presence of tremor, rigidity, bradykinesia, and

postural instability.









Table 2-2. Hoehn and Yahr Scale (1967)
Stage Characteristics
1 Signs and symptoms on one side only
Symptoms mild
Symptoms inconvenient, but not disabling
Usually present with tremor of one limb
Friends have noticed changes in posture, locomotion, and facial expression
2 Symptoms are bilateral
Minimal disability
Posture and gait affected
3 Significant slowing of body movements
Early impairment of equilibrium on walking or standing
Generalized dysfunction that is moderately severe
4 Severe symptoms
Can still walk to a limited extent
Rigidity and bradykinesia
No longer able to live alone
Tremor may be less than earlier stages
5 Chachectic stage
Invalidism complete
Cannot stand or walk
Requires constant nursing care

Videoradiography

Swallowing function was visualized and studied using videofluoroscopy. Patients

were seated upright and images of barium swallows were recorded in the lateral view. A

penny was placed behind the ear in order to have a referent of known length for later

displacement measurements. In addition, a headband with a hanging copper-lined

triangle (i.e., Chi-Fishman & Sonies, 2000) was in place controlling for head posture

changes and facilitating later displacement measures (Figure 2-1). A properly collimated

Phillips Radiographic/Fluoroscopic unit that provides a 63-kV, 1.2-m-A type output for

full field of view mode was used. Fluoroscopic images were recorded to a Kay

Elemetrics Swallowing Signals Lab (Kay Elemetrics, Lincoln Park, NJ) using a digital

scan converter and were electronically recorded at 30 frames per second.









Included in the field of view, at the very least, were the lips and teeth anteriorly,

nasal spine superiorly, cervical spine posteriorly, and upper esophageal sphincter

inferiorly, allowing for a complete visualization of the oral and pharyngeal structures

involved in swallow, specifically those needed for the measurements completed for this

protocol: the tongue, ramus of the mandible, hyoid bone, and upper esophageal sphincter.




















Figure 2-1. Example of Fluoroscopic image from where the measurements were
completed. Note penny and copper triangle headband for measurement
purposes.

Participants completed a dry swallow, six 5 cc. trials of pudding thick liquid

(Varibar Pudding-Barium Sulfate Esophageal Paste 230 mL 40% w/v, 30% w/w from E-

Z-EM) in a spoon, and six 5 cc trials of thin liquid (Liquid E-Z Paque Barium Sulfate

Suspension; 60% w/v, 41% w/w; from E-Z-EM) in a cup. Trials were presented in

random order, in order to control for fatigue and other effects related to order of bolus

presentation. In order to approximate the everyday feeding conditions of the patient, the

cup and spoon were utilized; all the patients fed themselves in the home, therefore they









self-fed during all trials. Patients were given the spoon or cup and prompted by the

clinical researcher to "place the liquid in your mouth and swallow when you are ready."

Data Analysis

Measurements Related to Swallow Timing

Measurements of bolus transit were completed by analyzing the recordings of

swallow trials frame-by-frame or in slow-motion using the Kay Swallow station. The

measurements were completed by an examiner trained in the analysis of modified barium

swallow studies. The examiner was blinded to the patients' identity. Tags were placed at

various swallow events in order to facilitate measurement. The swallow events measured

are explained in detail in Table 2-3. These measurements were selected in order to

capture the effects of bolus consistency on the timing of the swallow in persons with PD.

Using these events, measurements of oral and pharyngeal transit times were completed.

Table 2-3. Tags of bolus oral and pharyngeal transit times
Onset of Oral Transit Time Onset of posterior movement by the
bolus in the oral cavity

Point at which the tongue tip is raised
and the bolus begins posterior movement
towards the posterior aspect of the oral
cavity.
Offset of Oral Transit Time Point at which the tail of the bolus passes
the level of the ramus of the mandible
Onset of Pharyngeal Transit Time Point at which the leading edge of the
bolus passes the level of the ramus of the
mandible.
Offset of Pharyngeal Transit Time Point at which the tail of the bolus passes
through the upper esophageal sphincter
(UES).
Number of tongue pumps Number of times the tongue pumps
(rocks) while the bolus is in the oral
cavity, resulting in the posterior
movement of the bolus and the initiation
of the swallow reflex.









Measurements Related to Penetration/Aspiration

In order to assess the penetration/aspiration of swallows of different consistencies,

the Penetration-Aspiration Scale (P-A Scale; Rosenbek et al., 1996; Table 2-4) was used

to rate each swallow. The P-A Scale is used to measure whether or not material entered

the airway and if it did, whether the residue remained or was expelled. These

measurements were also completed using frame-by-frame analysis by an expert rater who

was blinded to the participant's identity.

Table 2-4. Penetration-Aspiration Scale
1 Contrast does not enter the No Penetration/Aspiration
airway


2 Contrast enters the airway, Penetration
remains above the vocal folds

3 Contrast remains above the Penetration
vocal folds with visible residue

4 Contrast contacts vocal folds, Penetration
no residue

5 Contrast contacts vocal folds, Penetration
visible residue

6 Contrast passes glottis, no sub- Aspiration
glottic residue

7 Contrast passes glottis, Aspiration
visible sub-glottic residue
despite patient response
8 Contrast passes glottis, Aspiration
visible sub-glottic residue,
absent of patient response
(Rosenbek et al., 1996)









Measurements of Hyoid Motion

In order to better assess the function of the hyoid bone, trajectory measurements

were completed. These measurements are used to determine the hyoid anterior and

superior pattern of excursion and depict the pattern of movement as related to the bolus

location.

The data was collected from two randomly selected swallows of six (three men,

three women) of the previous ten participants. The measurements were completed by an

expert rater with experience measuring hyoid trajectories. In order to complete these

measures, using dpsReality Video Editor, the JPG images for each frame of the

individual swallows were extracted. The images extracted were those between the point

when the bolus first began its posterior movement and the point when the bolus tail

entered the UES. These images were then imported and analyzed using a Matlab 7.0.1

routine (Wheeler, Martin-Harris, Bronsky, & Sapienza, 2006), which was developed at

the University of Florida.

The imported files were then presented in random order to the measure. The

measure picked two points in each frame. One point was the anterior most portion of C3

and the other the anterior portion of the hyoid bone. Once this was completed, the

program presented the frames in sequential order and the rater tagged the various

swallow events which were chosen for analysis. In this study the swallow events chosen

were: 1) onset of bolus posterior movement, 2) point when the bolus head arrived at the

level of the ramus of the mandible, 3) point when the palate first made contact with the

posterior pharyngeal wall, 4) point of maximum laryngeal elevation, 5) point at which the

bolus entered the UES, 6) point at which the UES closed, following the passing of the

bolus, and 7) point when the palate lowered from the palate. Once the analysis was









complete, the program provided a figure depicting the motion of the hyoid bone, a

spreadsheet with the angle and displacement measures, and figures representing

displacement and angle in pixels and millimeters. The program obtains the angle

measurements from a reference line drawn from the anterior portion of C3 to the anterior

prominence of the hyoid bone in frame one (Figure 3-2). The displacement measures are

also obtained using C3 as a referent. The use of the penny marker, allows for the

translation of pixel measurements to actual millimeters.

Figure 2-2. Figure depicting the reference line drawn from C3 to the hyoid prominence
in frame one and a second line from a later frame.


C3





Measures of Quality of Life

In addition, the patients' quality of life as related to swallow function was

measured using a perceptual self-rating scale, Swallowing Quality of Life Questionnaire

(SWAL-QOL; McHorney, Bricker, Kramer, et al., 2000; McHorney, Bricker, Robbins, et

al., 2000; McHorney et al., 2002; Appendix B). This tool includes questions regarding

both the oral and pharyngeal phases of swallow as well as appetite, eating duration, and

other factors affecting swallow function. Completing these measures allows for the

assessment of persons' awareness of their swallowing deficits.









Statistics

Primary Aim

A one way analysis of variance was used to assess the effect of bolus consistency

on the dependent measures (i.e., oral transit, pharyngeal transit, number of tongue pumps,

P-A score). Pearson r correlations were used to assess the relationships of the dependent

variables within consistencies. Lastly, descriptive statistics were used to identify outliers

and questions for further study.

Exploratory Study

Due to the small sample size in this pilot project, descriptive statistics together with

scatter plots and visual analysis of output from the MATLAB program were used to

identify trends, outliers, and evidence for formulation of further research questions.















CHAPTER 3
RESULTS

Primary Aim

Hypotheses 1-4 were tested by completing measures of timing and

penetration/aspiration on six thin consistency and six thick consistency swallows in ten

patients (5 male, and 5 female) with PD. The mean data for each dependent variable are

presented below in Table 3-1.

Table 3-1. Mean values for the dependent variables (for consistency, 1=thin, 2=thick).
Subj Tongue PA Swal-
No. Consistency OTT PTT Pumps Scale qol
1 1 1.527 1.561 1.000 1.333 176
1 2 4.433 2.389 6.833 1.000
2 1 0.945 0.889 0.167 3.333 208
2 2 5.533 3.139 3.667 1.333
3 1 1.374 0.823 2.000 1.667 211
3 2 2.931 1.716 4.000 1.000
4 1 0.553 0.656 0.167 2.833 207
4 2 1.079 0.959 0.667 1.000
5 1 0.729 0.998 0.167 1.167 204
5 2 1.187 0.623 0.833 1.000
6 1 0.295 0.489 0.500 1.500 138
6 2 1.254 0.470 1.000 1.167
7 1 1.193 0.642 0.167 1.333 156
7 2 1.604 0.612 0.500 1.000
8 1 1.146 0.842 0.167 1.000 193
8 2 2.261 1.269 2.333 1.000
9 1 0.361 0.762 0.000 1.000 211
9 2 2.475 0.548 3.833 1.000
10 1 1.035 0.646 0.000 4.000 212
10 2 1.182 0.642 1.833 1.167









Reliability

Pearson r correlations were conducted in order to assess inter-rater reliability for

measures of swallow timing and penetration/aspiration. All measures were found to be

reliable at p<0.05 showing moderate to strong correlations between the ratings of the two

measurers (Table 3-2).

Table 3-2. Pearson r correlation results for inter-rater reliability.
Dependent Variable Pearson r coefficient Alpha

Oral transit time .989** .000

Pharyngeal transit time .883** .000

No. of Tongue Pumps .759** .004

P-A Score .674* .016

*correlation is significant at the 0.05 level (two-tailed).
**correlation is significant at the 0.01 level (two-tailed)

Statistical Analysis

A multivariate analysis of variance (MANOVA) with covariates of gender and

consistency was completed in order to determine if there were any significant effects of

gender or interactions between gender and consistency on the dependent measures. The

MANOVA showed no significance for gender (Table 3-3). Significance level was set at

0.05.

Therefore, a one-way analysis of variance (ANOVA) was used to analyze the

results of the dependent variables (oral transit time, pharyngeal transit time, number of

tongue pumps, and P-A Scale) as a function of bolus consistency (i.e., thin vs. pudding

thick). Results of this ANOVA (presented in Table 3-4) revealed significant differences

(p<0.02) between oral transit time (p=0.008), number of tongue pumps (p=0.005), and P-











A scale (p=0.023) with bolus consistency. No significant difference was found for


pharyngeal transit time (p=0.196) as a function of bolus consistency


Table 3-3. Results of the MANOVA.


Multivariate Testsb

Effect Value F Hypothesis df Error df Sig.
Intercept Pillai's Trace .894 27.360a 4.000 13.000 .000
Wilks' Lambda .106 27.360a 4.000 13.000 .000
Hotelling's Trace 8.419 27.360a 4.000 13.000 .000
Roy's Largest Root 8.419 27.360a 4.000 13.000 .000
GENDER Pillai's Trace .221 .922a 4.000 13.000 .481
Wilks' Lambda .779 .922a 4.000 13.000 .481
Hotelling's Trace .284 .922a 4.000 13.000 .481
Roy's Largest Root .284 .922a 4.000 13.000 .481
CONSIST Pillai's Trace .688 7.160a 4.000 13.000 .003
Wilks' Lambda .312 7.160a 4.000 13.000 .003
Hotelling's Trace 2.203 7.160a 4.000 13.000 .003
Roy's Largest Root 2.203 7.160a 4.000 13.000 .003
GENDER CONSIST Pillai's Trace .291 1.332a 4.000 13.000 .310
Wilks' Lambda .709 1.332a 4.000 13.000 .310
Hotelling's Trace .410 1.332a 4.000 13.000 .310
Roy's Largest Root .410 1.332a 4.000 13.000 .310
a. Exact statistic
b. Design: Intercept+GENDER+CONSIST+GENDER CONSIST


Table 3-4. Results of the one-way analysis of variance (ANOVA).

ANOVA

Sum of
Squares df Mean Square F Sig.
Oral Transit Time Between Groups 10.924 1 10.924 8.743 .008
Within Groups 22.490 18 1.249
Total 33.414 19
Pharyngeal Transit Time Between Groups .824 1 .824 1.803 .196
Within Groups 8.224 18 .457
Total 9.048 19
Tongue Pumps Between Groups 22.396 1 22.396 9.951 .005
Within Groups 40.511 18 2.251
Total 62.906 19
PA Scale Between Groups 3.612 1 3.612 6.210 .023
Within Groups 10.468 18 .582
Total 14.080 19


Table 3-5 presents the mean data for each of the dependent variables for the thin


and thick consistencies. Oral transit time was longer with the pudding thick consistency


than the thin consistency. The number of tongue pumps increased with the pudding thick









consistency, than the thin consistency. P-A score was lower with the pudding thick

consistency than the thin consistency.

Table 3-5. Means and standard deviations for dependent variables as a function of bolus
consistency.
Thin Thick
Dependent Variable Mean St Dev Mean St Dev
Oral Transit Time 0.916 0.420 2.394 1.524
Pharyngeal Transit Time 0.831 0.296 1.237 0.909
Number of Tongue Pumps 0.433 0.625 2.550 2.028
P-A Scale 1.917 1.072 1.067 0.117


The third hypothesis was that there would be a significant negative correlation

between oral and pharyngeal transit times and P-A scale values for the thick and thin

consistencies. The fourth hypothesis was that persons with more impaired oral stages of

swallow would report more impaired quality of life. A Pearson r correlation was

conducted in order to assess the relationship between the various dependent measures

within each bolus consistency. Results of the Pearson r correlation are presented in

Tables 3-6 and 3-7. There were no significant correlations between the dependent

measures within the thin consistency.

Various significant relationships were identified within the thick consistency

boluses. For the thick consistency, significant positive relationships (p< 0.05) were

found between oral transit and pharyngeal transit times (p=.000, r=.939), number of

tongue pumps and oral transit (p=.007, r=.789), and tongue pumps and pharyngeal transit

time (p=.029, r=.683). No significant relationship was found between any of the

dependent measures and swallow quality of life or P-A score in either of the

consistencies.












Table 3-6. Results of Pearson r correlations within the thin consistency.


Correlations

Oral Transit Pharyngeal Tongue
Time Transit Time Pumps PA Scale Swal-qol
Oral Transit Time Pearson Correlation 1 .586 .515 .005 .074
Sig. (2-tailed) ..075 .128 .989 .840
N 10 10 10 10 10
Pharyngeal Transit Time Pearson Correlation .586 1 .314 -.248 .125
Sig. (2-tailed) .075 .376 .490 .731
N 10 10 10 10 10
Tongue Pumps Pearson Correlation .515 .314 1 -.212 -.013
Sig. (2-tailed) .128 .376 .557 .971
N 10 10 10 10 10
PA Scale Pearson Correlation .005 -.248 -.212 1 .390
Sig. (2-tailed) .989 .490 .557 .265
N 10 10 10 10 10
Swal-qol Pearson Correlation .074 .125 -.013 .390 1
Sig. (2-tailed) .840 .731 .971 .265
N 10 10 10 10 10



Table 3-7. Results of Pearson r correlations within the thick consistency.

Correlations

Oral Transit Pharyngeal Tongue
Time Transit Time Pumps PA Scale Swal-qol
Oral Transit Time Pearson Correlation 1 .939** .789** .408 .169
Sig. (2-tailed) ..000 .007 .241 .642
N 10 10 10 10 10
Pharyngeal Transit Time Pearson Correlation .939* 1 .683* .426 .226
Sig. (2-tailed) .000 .029 .220 .531
N 10 10 10 10 10
Tongue Pumps Pearson Correlation .789* .683* 1 -.003 .199
Sig. (2-tailed) .007 .029 .993 .582
N 10 10 10 10 10
PA Scale Pearson Correlation .408 .426 -.003 1 -.003
Sig. (2-tailed) .241 .220 .993 .993
N 10 10 10 10 10
Swal-qol Pearson Correlation .169 .226 .199 -.003 1
Sig. (2-tailed) .642 .531 .582 .993
N 10 10 10 10 10
** Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).









Exploratory Study: Hyoid Trajectory Measurements

Reliability

Recent investigations have found that the University of Florida hyoid trajectory

program measurements are highly reliable. A recent study by Wheeler et al. (2006),

found both intra and inter-rater reliability to be high (Tables 3-8 & 3-9).


Table 3-8. Intra-rater reliability for trajectory measurements
Dependent Pearson r Alpha value
Variable coefficient
Average Angle .942 .000
Average Displ .823 .001
Max Angle .945 .000
Max Displacement .872 .000

Table 3-9. Inter-rater reliability for trajectory measurements
Dependent Pearson r Alpha value
Variable coefficient
Average Angle .975 .000
Average Displ .895 .003
Max Angle .966 .000
Max Displacement .793 .019


Statistical Analysis

Due to the nature of this pilot work, (i.e., small n, no data norms) mainly

descriptive statistics (Table 3-10) were used in order to identify any possible preliminary

effects.

Table 3-10. Means and standard deviations of dependent measures as a function of bolus
consistency.


Dependent Variables Mean St Dev Mean St Dev
Average Angle 4.64 1.67 6.19 3.50
Max Angle 10.95 3.50 15.17 4.85
Average Displacement 3.41 2.58 3.11 2.26
Max Displacement 11.53 3.92 13.60 3.52
Average Velocity 43.56 11.06 46.33 15.99
Max Velocity 154.00 45.99 161.20 47.28


Thin


Thick













The means of all, except one of the dependent measures were higher with the


thicker consistency (Figure 3-1 -3-3). The only dependent measure where this trend was


not observed was average displacement (Figure 3-2).













......Average Angle
M Max Angle










Thin Thick

Figure 3-1. Figure depicting the change in average and max angle as a function of bolus
consistency.













C ..^ ^^ *Average Displacement
M Max Displacement










Thin Thick

Figure 3-2. Figure depicting the change in average and max displacement as a function
of bolus consistency.




















K AverageVelocity
U Max Velocity








Thin Thick

Figure 3-3. Figure depicting the change in average and max velocity as a function of
bolus consistency.

Case Studies

Below the data output from the MATLAB hyoid trajectory program is provided for

a single subject with both a safe (P-A=1) and unsafe (P-A=8) swallow.

Table 3-11. Order of swallow events and hyoid trajectory measurements for "safe
swallow".
Swallow Event Frame No. Angle Displacement Velocity
Onset Bolus Transit 1 0.157 1.279 42.641
Palatal onset 11 2.45 -0.154 34.900
Bolus at ramus 12 2.059 -0.609 15.144
UES opening 17 2.741 1.288 14.484
Max Laryngeal Closure 20 1.549 2.258 71.923
UES closing 27 0.220 5.028 17.711
Palatal offset 34 7.788 -2.136 32.096

Following are the figures depicting the trajectory of the hyoid in terms of angle and

in terms of displacement (Figures 3-4 through 3-9). Although the pattern of movement

is similar, in the "safe and "unsafe" swallows, in the "unsafe" swallow the first three

events (onset bolus transfer, palatal onset, and bolus head at ramus) have occurred within










the first four frames, whereas in the "safe" swallow the bolus doesn't arrive at the ramus

until the twelfth frame.

Table 3-12. Order of swallow events and hyoid trajectory measurements for "unsafe
swallow".
Swallow Event Frame No. Angle Displacement Velocity
Onset Bolus Transit 1 0.306 2.165 72.177
Palatal onset 2 1.586 -0.252 80.583
Bolus head at ramus 4 0.790 -1.630 34.430
UES opening 11 4.772 2.721 105.261
Max Laryngeal Closure 18 7.567 6.332 18.484
UES closing 23 5.487 5.425 31.386
Palatal offset 26 7.500 0.923 44.175


Angle vs time
-r -- -- r -- -t


200 400 600 800
Time in rriliseconds


1000 1200


Figure 3-4. Figure depicting the angle of the hyoid in degrees and the relationship to the
defined swallow events in the "safe swallow". Swallow events are labeled
with asterisks.










Angle vs time
-r --- -- r

,I, l







-x'\.


200 400 600 800
Time in milliseconds


1000 1200


1400


Figure 3-5. Figure depicting the angle of the hyoid in degrees and the relationship to the
defined swallow events in the "unsafe swallow". Swallow events are labeled
with asterisks.


Displacement of hyoid bone from C3 reference point


Ti 2in mii C secon
Time in mili seconds


ilnl 12--1 1400


Figure 3-6. Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the "safe swallow". Swallow
events are labeled with asterisks.














Displacement of hyoid bone from C3 reference point


0 200 400 600 800
Time in milliseconds


1000 1200


Figure 3-7. Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the "unsafe swallow". Swallow
events are labeled with asterisks.


Hyoid bone trajectory for single incremental step
? 320


a 340 _
. . .


120
no
1 330
?5n
>- 3G -



8 330

Q-


Hyoid bone trajectory for incremental step as 3


yoid bone trajectory for incrementa05 step as 5
Hyoid bone trajectory for incremental step as 5


350oi 305 i10
X coordinate position


Figure 3-8. Figure depicting the hyoid trajectory in the "safe swallow".















I
0


.-






>-
8
o0
Q-









0


CJ


Hyoid bone trajectory for single incremental step
350
350 /--------'-------'-------'-_ ----- ^L- ---

360 -
370
380 \
390 I
305 310 315 320 325 330 335 341
Hyoid bone trajectory for incremental step as 3
350
360
370-
380
" "n


305


350
360 -
370
380 -
ain /IIII


315 320 325
Hyoid bone trajectory for incremental step as 5


305 310 315 320 325 330 3
X coordinate position


Figure 3-9. Figure depicting the hyoid trajectory in the "unsafe swallow".


Below the data output from the MATLAB hyoid trajectory program is provided for


a participant with a shorter oral transit time because of little tongue pumping (TP=1) and


another with a much larger amount of tongue pumping and an increased oral transit time


(TP=7). P-A score was 1 for both swallows.




Table 3-13. Order of swallow events and hyoid trajectory measurements for shorter
swallow.

Swallow Event Frame No. Angle Displacement Velocity

Onset Bolus Transit 1 1.328 -1.028 34.262

Bolus head ramus 10 4.5023 -3.100 15.206

Palatal onset 45 0.808 3.632 3.141

Max Laryngeal Closure 50 4.280 5.223 6.767

UES opening 51 3.569 6.479 41.869

UES closing 58 3.234 8.438 26.700

Palatal offset 65 4.986 1.314 26.966


3:


5










Table 3-14. Order of swallow events and hyoid trajectory measurements for longer
swallow.
Swallow Event Frame No. Angle Displacement Velocity
Onset Bolus Transit 1 2.173 0.811 27.029
Bolus head at ramus 71 2.460 1.851 42.338
Palatal onset 145 10.920 7.282 61.012
Max laryngeal Closure 147 15.765 7.719 13.113
UES opening 149 17.825 9.339 41.617
UES closing 156 17.154 7.485 51.887
Palatal Offset 165 8.851 8.856 22.010

Following are the figures depicting the trajectory of the hyoid in terms of angle and

in terms of displacement (Figures 3-10-3-15). There are great differences in the amount

of movement of the hyoid, with much more extraneous movement of the hyoid observed

in the swallow containing more tongue pumping. The order of the swallow events is the

same in both swallows, but the distribution of the events throughout the length of time is

quite different.


Angle vs time
"""^ ^ T ^ ^


I 6-

4-



2-


0. ",1 100- l.j1 1--i ,.1 z,",l 2 ,
Time in milliseconds

Figure 3-10. Figure depicting the angle of the hyoid movement and the relationship to
the defined swallow events in the shorter swallow. Swallow events are
labeled with asterisks.











Angle vs time


Time in milliseconds


S\














', ':,


Figure 3-11. Figure depicting the angle of the hyoid movement and the relationship to
the defined swallow events in the longer swallow. Swallow events are labeled
with asterisks.


Dispacement of hyoid bone from C3 reference point
66

64

62

60

E 58

E 56

-L 54

52K
50- I '. .



48

46
0 500 1000 1500 2000 2500 3000
Time in rrlliseconds

Figure 3-12. Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the shorter swallow. Swallow
events are labeled with asterisks.












Dispacement of hyoid bone from C3 reference point


'I


0 1000 2000 3000 4000
Time in milliseconds


Figure 3-13. Figure depicting the displacement of the hyoid in millimeters and the
relationship to the defined swallow events in the longer swallow. Swallow
events are labeled with asterisks.


Hyoid bone trajectory for single incremental step


C~ ----


2-d5 2eJ3 285 e9 2-'5 3,. 3la 2'10
Hyoid bone trajectory for incremental step as 3


Hyoid bone trajectory for incremental step as 5


290 295
X coordinate position


Figure 3-14. Figure depicting the hyoid trajectory in the shorter swallow.


5000 6000


7000









38






Hyold bone trajectory for single incremental step
=60


1300 -


>- 340 -
260 265 270 275 280 285 290 295 300
Hyoid bone trajectory for incremental step as 3


S280


4 kn
t II,*-


y-30
..60 2L- 2r 275 2 u -.65 ; -.95 300
Hyoid bone trajectory for incremental step as 5



2 8



>- 340
265 270 275 280 285 290 295 300
X coordinate position


Figure 3-15. Figure depicting the hyoid trajectory in the longer swallow.














CHAPTER 4
DISCUSSION

The current study assessed the effects of bolus consistency on swallow timing and

P-A score in persons with PD. The findings were mainly consistent with the hypotheses

set forth, with the exception of some minor differences that will be discussed in greater

detail below. The current study also presents exploratory data quantifying the motion of

the hyoid bone in relation to measures of bolus transit and penetration/aspiration. These

measures were obtained utilizing an innovative MATLAB program which provides

information about angle, displacement, and the order of events relative to hyoid motion.

The following discusses the research findings and their clinical importance.

Primary Aim

Measures of Bolus Transit

When measuring bolus transit, the primary dependent variables included oral transit

time, pharyngeal transit time, and number of tongue pumps. Both oral and pharyngeal

transit time have been used to address bolus transit in varying populations (i.e., De

Vincentiis et al., 2004; Han, Paik, & Park, 2001; Monte, da Silva-Junior, Braga-Neto,

Nobre e Souza, & Sales de Bruin, 2005; Nagaya et al., 1998; Robbins, Levine, Maser,

Rosenbek, & Kempster, 1993). In the current study, a significant difference was found in

oral transit time as a function of the thickness of the bolus, with oral transit time

increasing with thicker boluses. These findings are not surprising. Past research has

found that thicker consistencies lead to greater oral transit times (Dantas et al., 1990), but









this relationship had not been identified in the PD population, nor has the cause of the

increased oral transit time been discussed.

Increased oral transit times can be caused by various factors, many of which are

related to the motion of the tongue. The presence of tongue pumping in persons with PD

may not only affect the bolus movement from the anterior portion of the oral cavity to the

posterior portion, but may also affect the strength with which the bolus is propelled into

the pharynx. Although the presence of tongue pumping, also referred to as destination of

the tongue or lingual rocking, has been identified in persons with PD (i.e., Hunter et al.,

1997; Leopold et al., 1996; Nagaya et al., 1998), quantifying the number of tongue

pumps has never been completed to the researcher's knowledge. This measure was

selected as the most obvious characteristic of the oral phase of swallow in persons with

PD, which was associated with an increase in oral transit time.

Results identified not only the effect of the differing consistencies on oral transit

time, but number of tongue pumps as a predictor of increased oral transit, with a

significant positive correlation found between number of tongue pumps and oral transit

time. This significantly positive relationship was only identified in the pudding thick

consistency. There was also a significant difference between the number of tongue

pumps in the thin versus the pudding thick consistencies. The literature discussing the

festinating tongue phenomenon states that this process is caused by bradykinesia and

rigidity of the tongue (Bushmann et al., 1989; Edwards, Quigley, & Pfeiffer, 1982).

There is little explanation as to why the tongue pumping does not occur as frequently in

thinner consistencies, or why there is no relationship between oral transit time and tongue

pumping in thinner consistencies.









It can be hypothesized that the thinner boluses lack of resistance to flow may

reduce the need for oral manipulation, thus causing spillage into the posterior portion of

the oral cavity, and possibly the pharynx. Since those with PD have difficulty

coordinating movements, as well as slowness and weakness of the oral musculature, it is

possible that the bolus moves to the posterior portion of the oral cavity before the

structures are prepared to receive the bolus and trigger the pharyngeal swallow. It is for

this reason that the relationship between tongue pumping, pharyngeal transit time, and P-

A score was addressed.

A significant relationship between tongue pumping and pharyngeal transit time was

identified through Pearson r correlations, with pharyngeal transit time increasing as

number of tongue pumps increased. This relationship provides insight into the

relationship between the oral phase of swallow and the pharyngeal phase. Even with this

defined relationship, a significant difference in pharyngeal transit time between the two

consistencies was not found. The fact that pharyngeal transit time did not change

significantly as a function of consistency may be due to limitations of the study like small

sample size and small bolus size, or may be due to the reflexive nature of the pharyngeal

phase in comparison to the more voluntary nature of the oral phase of swallow; especially

in this population who often exhibit more impairment in voluntary than involuntary

behaviors (Yamaguchi & Kabayashi, 1998). However, this does not explain the

relationship between tongue pumping and pharyngeal transit time. The fact that tongue

pumping was associated with increased pharyngeal transit time in the pudding thick

consistency, provides further support for the consideration of the swallow mechanism as

a more cohesive unit versus a mechanism consisting of separate phases which in the end









add up to a swallow. In addition, this data supports the case that the pharyngeal phase of

swallow, although reflexive by nature (i.e., Huckabee et al., 2003; Martin et al., 2001;

Martin & Sessle, 1993; Mosier et al., 1999), is also controlled or influenced somewhat by

voluntary mechanisms (Wheeler & Sapienza, 2006). In the case of this participant pool,

it can be hypothesized that the dysfunction of the base of tongue may have reduced the

pressure with which the bolus was propelled down the pharyngeal cavity, which could in

turn have had repercussions on pharyngeal transit times.

In summary, the data supported the hypotheses set forth by the investigators. It

was hypothesized that both oral and pharyngeal transit times would increase with thicker

consistencies versus thinner consistencies. Although the means were greater for both oral

and pharyngeal transit as a function of bolus consistency, pharyngeal transit did not

demonstrate significance. This finding also supported the hypothesis that oral transit

time would be increased to a greater degree across the consistency condition. Lastly, it

was hypothesized that the number of tongue pumps would increase significantly with

thicker consistencies, as was found in the data.

Measures of Penetration/Aspiration

Past research has found that thicker consistencies are safer for persons to ingest

than thinner consistencies because they reduce the possibilities of penetration and

aspiration (Bulow, Olsson, & Ekberg, 2003; Kuhlemeier et al., 2001). It is on this

premise that diet modification recommendations (i.e., thickner for thin liquids, or

modification to puree consistencies) have been based. A significant difference was found

between P-A score as a function of consistency, with P-A score being higher (less safe)

for thinner consistencies, supporting one of the hypotheses set forth. Interestingly, the

hypothesis that there would be a significant negative correlation between oral and









pharyngeal transit times and P-A scale values for the thick and thin consistencies was not

supported by the data in this study. Pearson r correlations did not show significant

relationships between oral transit time, pharyngeal transit time, and/or tongue pumps with

P-A score. This is somewhat surprising given the strong relationship identified in this

study between consistency, increased oral transit and the number of tongue pumps, as

well as the strong relationship identified in prior research between thicker consistencies

and penetration/aspiration of the bolus. Further discussion on the variables which could

have possibly contributed to this result are to follow in the discussion of the study's

limitations.

Quality of Life

It was hypothesized that persons with more impaired oral stages of swallow would

report more impaired quality of life, but no significant relationships were found between

swallowing quality of life and other dependent measures, including

penetration/aspiration. This may be explained by the "anosognosic" nature of persons

with PD. This population is often considered to have decreased insight into their own

behaviors and medical severity (Starkstein et al., 1996, Seltzer et al., 2001).

Interestingly, the oldest participant reported the best swallowing quality of life, although

both the oral and pharyngeal phases of this participant's swallow were no more or less

impaired than most of the other participants. This apparent reduced reliability of patients

with PD to recognize or quantify swallow impairment is important to note clinically.

This lack of insight may prove detrimental to health and safety in later stages of

dysphagia. It is therefore the responsibility of the clinician to judge a patient's insight

into their own disorder, be it through interview or more extensive neuropsychological

testing, in order to make wise decisions involving management of dysphagia. These









issues can have negative implications for compliance of dietary modifications or use of

compensatory strategies, and/or may negatively influence therapy outcomes.

Exploratory Study

The hyoid bone is an essential member of the swallow mechanism. Together with

the suprahyoid muscles, this bone moves superiorly and anteriorly raising the larynx

which ultimately protects the airway during swallowing. Before the UF hyoid trajectory

program was developed, there had been no way to quantify the movements of the hyoid

and relate them to various swallow events, in an automated, time efficient manner. With

this program, investigators are able to quantify the angle and displacements of hyoid

motion during swallow. In the current exploratory study, these measures were obtained

and then compared to timing and penetration/aspiration measures in order to identify any

preliminary relationships between the hyoid motion and factors relating to swallow

timing and penetration/aspiration. In addition, various swallow events were overlayed on

the hyoid trajectory measurements in order to better identify and describe the factors

contributing to a safe or unsafe swallow. Also, the pilot data that was presented in the

results section was obtained and compared to the preliminary data of healthy adults.

These comparisons were made in order to identify differences in the motion of the hyoid

bone as a function of disease process, and thus describe factors which may be influencing

swallow safety and timing in patients with PD compared to healthy adults.

Comparison of the means of the various dependent measures acquired from the

MATLAB program (i.e., average and max angle, average and max displacement, and

average and max velocity) as a function of consistency showed increases in all the

measures related to hyoid movement with increased bolus thickness, except average

hyoid displacement. This is consistent with past research which has shown that with









increased bolus thickness there is a greater activation of the suprahyoid muscles as

measured by sEMG (Dantas & Dodds, 1990; Ding et al., 2003).

Preliminarily, it seems that there is a relationship between angle size and

penetration/aspiration of the bolus, but not a relationship between displacement and

penetration/aspiration of the bolus. Within the thin consistencies, the participant with the

largest average angle presented with a very safe swallow, and the person with the

smallest angle was among those with the least safe swallow. In addition, the latter

participant presented with the smallest maximum angle size. This is especially

interesting in light of data from healthy controls (Wheeler et al., 2006) which found that

angle was the only measure (of the dependents described above) which was not

significantly different from person to person. In other words it was the most consistent of

the measures within healthy controls, yet in this population of persons with PD there

seems to be great variability in the degree of angle produced with each swallow. This

increased variability may be consistent with decreased coordination of swallow and

subsequent differences in swallow safety, specifically penetration/aspiration.

A case study presenting evidence of decreased coordination of the oral-pharyngeal

phases of swallow resulting in an unsafe swallow was introduced in the results section.

In this case, one safe (P-A=1) and one unsafe (P-A=8) swallow, within the same patient,

was analyzed in order to compare hyoid trajectory measures. It was observed that

although the trajectory pattern itself was not much different between the two swallows

and the order of the swallow events was no different, the speed with which the swallow

events occurred was quite different. In the "unsafe" swallow, the bolus arrived at the

ramus of the mandible by the fourth frame, whereas in the "safe" swallow the bolus









arrived at the mandible in the twelfth frame. One could hypothesize that in this

population, faster is not better, in terms of swallowing function. In this single case, it

seems that the discoordination of the swallow mechanism may have led to a rushing of

the swallow events, and subsequent aspiration. The relationship among increased speed

of bolus events, together with discoordination of the swallow mechanism, and

penetration/aspiration is disconcerting in this population which often presents with

decreased cough strength (Ertekin et al., 2002; Hunter et al., 1997) and limited insight

into their condition (Starkstein et al., 1996, Seltzer et al., 2001; Kleinow et al., 2001).

Also interesting, was the absence of any recognizable trend between displacement

and angle measurement or displacement and penetration/aspiration of the bolus. These

findings challenge past research which has defined both the superior and anterior

excursion of the hyoid bone essential for swallow (i.e., Logemann, 1983). The current

pilot data would suggest that perhaps the angle of the hyoid motion is more important for

a safe swallow than the hyoid displacement in the anterior or superior direction alone

In terms of the thick consistencies, much variability is present in hyoid motion due

to the increased amount of extraneous tongue movement associated with tongue

pumping. Because the tongue and hyoid bone are attached, it makes sense that tongue

movements would result in movements of the hyoid bone as well. The importance of

these movements and their effect on subsequent motion of the hyoid related to the

pharyngeal swallow are yet to be identified. It is challenging to discuss these data as

there is no obvious trend to the tongue movement, but it is interesting to note the close

relationship between these two structures which are essential components of the swallow

mechanism.









Limitations and Strengths

There are several limitations to the current study. Primarily, the present is a small n

study whose goal is to identify areas for further research and identify differences which

are present in the oral and pharyngeal phases of swallow as a function of consistency in

patients with PD. The nature of this small n study limits the generalizability of the

study's results. Also, the population which was recruited for this study, although

homogeneous in their clinical severity, may have been too mildly impaired to show true

effects of the dependent variables on P-A score. The lack of pharyngeal dysphagia in this

current participant pool, may have acted as a ceiling effect due to the fact that many of

the patients presented with relatively "safe" swallows, and most did not aspirate.

Although this is true, the trends which were observed are useful for predicting changes

which may occur in patients with PD who exhibit more severe dysphagia. A ceiling

effect may also have been caused by the size of the bolus. The five cc. bolus may have

been too small to truly tax the system and show changes which are representative of real

life swallow challenges.

This being said, the current study is the first of its kind, studying timing and P-A

score as a function of consistency, in a well controlled population, while concurrently

obtaining data which greater specifies hyoid function relative to these variables. The

current study controlled for medication state, with testing one hour after medication

dosage, and controlling also for clinical severity of symptoms. Also, randomization of

the bolus presentation controlled for the possible effects of fatigue. The presentation of

these randomized boluses using cup and spoon, versus syringe, made for a closer

simulation of the participants' daily eating routines. Lastly, the researchers controlled for

other medical diagnoses, which could have affected swallow function, these included









dementia (i.e., Amella, 2004; Dahlin, 2004; Kalia, 2003), other neurological conditions

(i.e., Logemann, 1983), head and neck cancer (i.e., Pauloski et al., 2002), and certain

respiratory conditions, including COPD and asthma (i.e., Good-Fratturelli, Curlee, &

Holle, 2002).

Implications for Future Research

In terms of the primary aim of this study, there are many more questions to be

answered relative to the changes which occur in the oral-pharyngeal phases of swallow as

a function of consistency differences in persons with PD. Now that a possible difference

has been determined between consistency and penetration/aspiration in PD, and a

preliminary relationship between tongue pumping on bolus transit times has been

identified, research should focus on more specifically defining the changes which are

taking place. Manometry would help assess the pressure changes which may be

occurring at the base of tongue, causing subsequent changes in the pharyngeal and

possibly the oral phases of swallow. The effects of bolus consistency on the relationship

between swallowing and breathing in patients with PD is also an interesting question,

especially due to the respiratory changes which often occur in this population, and the

presence of dysphagia which had been described in populations who exhibit respiratory

compromise (i.e., Good-Fratturelli et al., 2002). Lastly, including participants with PD

who exhibit more impairment of the pharyngeal swallow, coupled with the use of a larger

bolus may help assess more specifically the safety issues, particularly P-A score, of this

population with high risk of death secondary to aspiration pneumonia.

Implications for Swallow Intervention

There are more questions than there are answers concerning swallow intervention.

Even today, clinicians will limit patients PO intake or modify their diets long before it is






49


necessary. This is driven mainly by a paucity of literature describing the physiology of

swallow secondary to variables like consistency and compensation strategies, in addition

to questions related to aspiration; its effects and repercussions. It is the hope of the

investigator that through this and future research, the many remaining questions may be

slowly addressed, and the quality and length of life in persons with PD and other similar

disorders may be enhanced due to better management of alimentary issues.















APPENDIX A
UNIFIED PARKINSON'S DISEASE RATING SCALE (UPDRS)














UWPIMED PARUMMMd3 DUEAE RATIP402 SCALE


I- WIWA TX1f RiNAVTfl AAW M300

t. Lort-awtaml Imalarnmill
* ftrai.
I Mlld. CUmdElFAr *mdai1am4 wNK ; &,t a uwaablct1.1 I arsi dnt ua -thw diflfcukn..
I. do' nTna.. km, l uss h w nl u k art or an! andco1. dithlculp hlidllig E3lrpla pralmmmm. Mild but 4041Fr~
imp.irnwlit 41 rinctar it inn. slith aBd & accmmiai ;rmnin.iq.
3 Sw'u omummy a am with &mriibaor' k- Urra ard cali. t ;la*, 5a..I4 Iropiori. In handiCi4 praIlrm2.
4 Swom~i nTnia. aim wNK cyrH ati prmrirm bz pmwcii aiIy Unmhbe In mohn JudCjrm44Lu Cy Iulv pravimim
P:-ML rum nu h hmJl rwlti porraniml c .Canr ltu laft Ii. rm atall.

Z. Tbnught Odw.4ar 4Dai i dLm4lnH c y rug Iintilcoiki
0 ftVAi.
I fluidd 4mrmir..
I BanIgn-iaIuz n or. Ic~ na b I nagM reth In a.
3 OCCO1131 -.. kuquent A.iIam.Ik41E or cialumoura; .mllh~ul In. qi:; could I.tailam withi daly amtvim.
.4 Pwmtmiait is ucmUandm, daLwaram, cu fcr~ii pnpch~aIm. 4&t ibla in Ec
T. Da p '.4. mm n
I* P rIdE ni a .ad n~ marmc g Ll I ~ranu hIar n r mm~ sliLw mnianmnd hi r d myi a m a-
I -*u bmIjra~id d W ura r L I a owk ar ri ara.s.
3* SiJ.Lalrm. dnffpmmmi.Hi Wh EagotoleE m% iptaiii (ILmzvLhm, sourexam, uslodt Roma, Icamm COilmmd
4 Sumbianid dE9Iemocion wIit v~agtbwe mVfEiptaE and zKiEI4Itfal iauht cc Iib~nL

4. Diattkwor a of InHffh
* flarrp~a.
I I amoanmartI Ivathanu i umu1i rr ara pm1: m D
2 Lum. d hIn 1: n Iv !~ ~I iIr r mat I: .Ii a- :1 % .C.m i.niacbiite]:h mit in .
3 Lain I hInmItiin vac o Mr ourmat In d my n dm y 4rajutine I :- :mn
4 W* k rN irrwr wc-nipumil Roma r cr .ntiHac


EL ACY1TIE~r -OF flAZE LrVINrG e fw haii -am j .rgj

S.1 poch
* ftarn~j.
I *blcl~ ,Mj ffcd Ka d 17 Eui:. -- n; -jnftdAH
I Kncmbortop aFNacted. Sautrmarike imbk to repas zktma~naah.
3 Simmanu~y miwlod rm; aimit y makdL tintmt almm~urat.
4 LrdnI~tglbis, rm>t f -:h& tini..


* flarrp~a.
I !Ploj 1 Mt.ratmAT EEEUimimi. maillwa; n m~ ama m~inimal dracIlag.
3 PMwtd mucmar aO aJimm with mana dr.aniri.
4 Mmoked druaflag, rmqwr ccmtmk it m ouerfahr~dicorchI~.


C harr mi.
I KiREM EtIckIg.
I ch~czauiaaicha
3 NRuqIrm .zft I=
4 RoNayirm.. NG~ Lb*b a'r gusrctaiT f~adg.

IL Ha nA. ri i g
C Farn mi.
I *f UW Elaw -M 3miI1.
2 Ha M~w olalp slw ar an ad iLl wPa rd aau* Ia~.
3 I rl5 *fo Iwd m id : nat al I wia rd.sw a;~I b a.
4 *Tku rsmaialmyawf acif renon lgIbIh4&

-IL C uttig ft~pd amnd la..~g utsm Ho
* ftarn~j.
I Sarawl~im miun ai~d cummiy, bilk r. h" neamAmw
2 Can cut miza fandm, L~ithauh Eihunmy and mtc; narmE help ireandad
3 Pti! miu be cat by~ mannmarNu but can,~ 011 fama zwliF.
4 *Nomdr In ha (ad-









52



in. Drualng~

I 5,4rru t :I;Fw, but no heftp a*dad.
2 0cmCa.nal acrsistirwe with buttoning, gdtting armw Irk sleeyes.
3 Cornl-duarati hIep rqnuIrt, but can do son thirkml aiom.
4 = Hulplesh-

L1. tvg~rba
ci Normal.
i 5OMaMt stow, Wat ma heI P nei*add.
2 Meads help tD sawwar or bathe: or Yery sI ow In hylenic care.
3 Requilres &lsltarc 10fr walrhing, brush ln trath, conbintl hair, WIng~ to bhalthmol.
4 Folay catheter or ohklar mrbbanimkl akd[.

iL Tuirag lin hbod arid ad~ustimb Iado e.
ai morrral.
L 5arnewbat iow and cluany, but no haip n.40d.
2 Can lani alone or adjust sheets. bat ift ra dgrea d[tt-.
3 LAn ItitLat., but not turn or "dJust sbheet ahm..
4 HuIplussi.

13. Fallkig (nrallted to ftizuingi
ci Mane-
I Rare Waing.
2 CbcasIhmaIIy thus, hLma tMrn oic por day.
3 Falls an merage of rnca dafy.
4 Falls mau than onca daffy.

LC Fmurezrg whom malkitig
ai Mane.
L Rara freezing when wafting may have startt-intation.
2 Occj&lonl r1reazing when 'odaakn9.
3 Fraurn t rrc2l g Ocacstof y a I I V rom rnmzk.
4 Fraquant rails from fRazzlne.


ci- orrrd..
i Mild dlcuCltT. Nay WoI riulng arrdb or may te nd to drag tMg.
2 MCodrate dHr4cultyt, hut reirru littleor ri awdlstarme.
3 Severe disturbance DI walking, raquIrIng assistarie.
4 Cannot wvalk at all, evar withi oielstare.

iS. Tr~ar C Syrn ptomatk corylahnt otrae nm In ay Part o body.l
0 Absoent.
I Sight and lnfqantl)f present.
2 M4o40ratc: bothirsorma ft "paltnt.
3 Savere; intarteres with marwq adNflf
4 R1ked; Interferes wMr L mout actI'feIs.

iU. IuftBMF carnilailrt related to pakliuilarn
ci lant-
LI = lccEilonall har. niumbness, tingling. or mild aching.
2 Froguuntly fhis nlrnimess, tingling, or adchin; not dletreaoiog.
3 Fraqurrit palinul stnsaltnat.
4 Ekr uclating pafi.


1)1. MOTOR EYA WINA T70N

LB. Bpeach
ci INor read.
L SllghRt lads of expremloin, diction andGr Yolame.
2 Mtornotone. sluirud but undersarndzibc rnpdaraftely impalred.
3 MarUdA Lmnparlmnent d[MkuIt to malderratand.
4 Unintelligibl.

ID. Facial Ewpr.sictm
ci born-a.l
i Ninlr nal hyLrnmlla, cold be normal 'Poker Fae's.
2 = Slight hut daflnfltely abnormnal dlrinuitloID oIwJul c5:pnmplr c
3 N oderale hyprruda; IE" parted some of the tirne
4 Na ror Fixed facdb with saeyre or complato loss of radal amprasaon: Nps parted ir4 dich or rmore









53



2D. Tranor at rist (iead, upper and hower eictremitles)
C Arsent.
I Slight and Infrequentlr present.
2 M ld In amglltude ard persistent. Or maoderat In amplltude, but only InterrnIttanlr present.
3 Moderate In arrplitude and present most of the time.
4 MNarked In amplitude and prrenlt most ca Ith time.

21. Action or Potiurl Tramn of harnA
S- Absent.
L SlIht; present with actkin.
2 Modrate In amplitude, present with acion.
3 Moderate In amplitude with posture holding as well as actJon.
4 Marked I amplitude; Interfers with fc~ding.

22. Illgity (uilged on paClsv rmrovmenat of major joint with patient relaMi In sitting position. CIogwhellnl to bh
Ignorcd.1
C Absent.
L Slight or detectable cinly when activated by milrrr or ather rnvernrrets.
2 M Id to rrde.rate.
3 Narked, but full ranrg of motion eanily archltld.
4 Stera, range ol mrtcin achieved with dhiaiBlty.

23. Finrar Tap(iPatlInt taps thurrib ni wth IndX fnger In rapid succiskin1-
0 HI rr2I1.
L Mkd slcuIrng and.'r reduction In amplitude.
2 ModeratNly Impaired. Definite and early fatl.ulng. May have occasmlnal arrets In mnoermeut.
3 ~evertl Impaired. Frequent hspalian In Initiating m~rvements or arrests In ongoing ~yFvmert.
4 Can barely prrorm the task.

24. Hand Ca ioirlnte [Pataint Ipen r and closer hands In rapid succ~slan.I
0 Norrral.
L MMid stunii and.ar reduction In amplitude.
2 ModeratIly Impaired Dafinite and early fatlgulng. Ma' have occas.lonal arrest In r.oyement.
3 Sevcrely Impalred. Frequent hesitoli I In Initiating rwrve r nt or arretz In ongoing rrwnemerit.
4 Can barrel perfirml thE talk.

25. Rapid Altanati ng lodli enamit H ands (Proniatlion upination movmin ts hands, V rtHally and hortrntal I,
with a large an amnplitud as p-sslble, both hand. si multan ously.
0 Horrml.
L MIdd stlcm r andhar reduction In amplitude.
2 Moderately Impalired Dlinite and early fatlnulng. Ra'r have occarslnal arr-est In ioe menuct.
3 Bevcrely Impaired. Frequent hesitation i In Itlating rr vu r: nts or arrest In ongolin rue metnt.
4 Can barely perform the task.

2&. Leg AlUtyv (Patient taps bhel on the ground In rapid successlon pickling up entire eg. Ampldtudae huld be at least
3 Indihe.)
0 Marrrril.
L M Id slMlrod and.ar reduction In amplitude.
2 Moderatily Impaired. Dfinifte and early fatlnulng. Ma'r have occailnnal arrests In Ionemernt.
3 Sevrely Impaired. Frequent hesltatlin In Initiating rruvemrnts or arrest In ongoingD navemerit.
4 Can barely perform the task.

27. Artsdrbg Iroman air (Patient attempts to rise from a stralghtbacked chalr, with arms folded across chest.)
a Hcirrmal.
L Skow: or nuar need mre" than one attempt.
2 Purhes seil up from arm; of seat.
3 T ndi to fall back and may have to try mre than oe tlrne, but can get up without help.
4 Unahbla to arise without help.

2t. PeLtuir
O Norrrl erect.
L Mat quite erect. sit1p toped pasure.: couid be norral fbr older person.
2 Moderately stooped pasture. definitely abnormal; can be slightly leaning to ore side.
3 5e4arely stooped posture with lkphosis; can be moderately leaning to one side.
4 Marked Nerlon with aetrenrr abnirmuality 'r posture.

G2. ailt
0 MHrrnMl.
L Walks slowly, may shuffle with short steps, but n festllnatlom (hastening steps) or prmpulslon.
2 Walks with difficulty, but requires I title or nro asistance: may hau :orrm fstlrnation, ;hrt steps, or propujlain.
3 Sevre disturbance of Dalt, requiring asastarce.
4 Cannot walk at all, ev'r with assistance.









54



30. Facritural IthIttv{Raspni to Suddoi, srt q postrcrl,rdIIspiaerrnt pr"dLzod by poll an ihouJftm whM Vpalleat
eret with eM Cort and feat ilghtlf a rt.. P atlint lr prep 3red-
- INrrOmad.
I Retrapijlson btat rncyrm iuralided.
2 AbsenfA of potiural resj~an: woird fall N not caLwghi tr xamirbur.
3 VeMry unstAbt4, tufnds to tos bhaiarne spantauniusly
4 Urwklu to sand afthoat alrtanciL

3i. &~dV Bradvklnnsd wid Hp.WeIlAaia 4Canbining dowmass, hsiftairm, decrsasa Mrrmiwvri, small alnpbttude. and
pymarty a tr iwmarit IE gcilua.l)
in- IN CMO-
I Minimal ulownes, Igulnrg mfm"Pnl a d.Ubirate character: could be iorrnal frnorsore ersons. PCaslbly raduced
armpIitLpft.
2 MINI d4.r z u nslaxa and poverty or man-rrmtit ihadi U deflltitai aliiomal. AitEmctIayly, soian reduced
ampIltLEud..
3 Ibecra c! r.lawnes, protrty or zrnil aruplllitdud of' rayueset.
4 larlked slawoas, poay" of sma amiplitude ol mfafm arkt.


P1_ CICWCUPLhATIONS tW TANA9IA il tHm Best mmaskl

A. EINNI(INESUR

32. DCiwtlori! Wlht pieopactlu af t wakingdaii dav rr il miuflrwolua pjFuil (~Hkrcsa lwfcrmifnt.m

-I 1 25% cedat.
2 26 % Wf' o day.
3 51-75% W dayo
4 76SAGIIa ICI d"p.

33 KilsabUifty- W-lbw diablln ar tha dyskinmLkO (+Rlataiical ltcmrartia rmay ha r3 h- orrice eIarnlnathm.
0 Mat d lablIllmg
I 101Mdly disat-lin
2 ad1asaftly dkaktllrg.
3 5.rruI: dLsa~lrc~.
4 opleverly tlft blind.

1,4. nnuMil DclmeaLn How pirphl are Ithe dysildroias
10- Me painful "ynesnfas
I Sligh~t.
2 Maderat..
.3 -Scerc~.
4 -Marke..

Ii. Pret.a"e fl Eally HaMwfIn Dyst'cra 4H H[Calka i forrtcIi.i
in- Eo
I YES

EL CLUWINAfi FLIC1UATIONS

11. ra '.olfr pkriodm prkdlctable?

I Yes

37. Ama mfF pmwaod unpbedctalblia?

I YES

38. Do "off" periodis cAu &n suddainly. wltgni a law socondi?

I YES

I3. Wlat pIcopotlo all tiM. wakkq diaV I s h peleit "Il l- anvwrarga
a- bIl~e
I 1- 25% day.
2 26-M5% W day-
3 51 75'h W day.
4 76 1Ab% eday.

C OTHER IL CC IM4WATM

40. Does tMA palhkit huveaaaw lamt mua, or iormltling

I Yes














41. AzuV awo disturbabemx, each as Imo.r a orWpersaru lcm
10- No
I Yes

42. Dome the paletil hava ow'nWpermat oafltasul?
C Record Uth paUent's blood pcesre, hrithl amid wdgtht mDn tih csnln~ i or
a No
I yes


V_ MhDIPIE HOEHNA ANDl VTAJ I S IAOnt

STAGE I] No srlgmi oCI seac
STAGE i Unlatural dk&a.
STAGE i._ Uridlatral r-lus axlal IrYWoYermmt.
STAGE 2 Eylateral dIscaie, without Imparrment or balance.
STAGE 2.5 MCld blatural disca. with rozry oin pufl last.
STAGE 3 Mild to moderate bilatural disease; siore Postural EIstAb4t; phyiskilly Inhdapandent.
STAGE 4 Savrn disabiitWy; still abla to waft cT stand urh5Lrt4rL
STAGE 5 Witealchair htiound or bedriddrn irmIess aldd.


VI SCHWAB AND PYSLAND AC77VYTES OF IMAIL TVI1 -q IA

1110% Completely Indepan~dut. Able itn c~c all chortt without sIonuass, d'ltMcuiy o Wnmpadrrnwnt. EssntaullI mwnrmal.
Linwe .a ofani dhirvijty.
91196 ComplIettt Independfnt. Abic to do al ch ru ns h snmbe fpree cf slownhss, dtfcuRty aand Impalrrment. MNight
take twica aL Iong. BEklmallri to be aware ar dlttfuluy.
4111% Cpompetely Independent In most dhrnrr. Takes Iwica s lans Ccisiduccs of OlIkcuEV amd stowmass.
741% Hat completeIf Indepcndcnt. Hamo dc'llcufty with sm chores. Three ect rmur times as krflg In mamn.. Must "pend
a largu part of the daV with chorer..
G0Ab :Som dependency. Can do mail diores, but .ehccdIngIy slowly I rund with rrwcllh ,!ort. Error: scrrna Impossbile.
SO%- MorE depndent. HaV with haff sIker. tet c- lcuIlt'y with eiarything.
44% Vcrr dependent. Can assist with all chores, but few alone-
311% Aith effort, now arid ther dloes a low chores aloi1or begirtsalone. MLch help neoded.
2110A MathlMn aone. Caor be a siIght 1harp wit hsom chir". Svvru Munaild.
111% Totally depeideantr hfltuss. Complete Irwulaid.
Or%- IeUat at I'm tutlons sch as aI lo wIIniq, bladd orrad bowel I functlors are rot IL1Joe ni q- Bedr dido.















APPENDIX B
THE SWAL-QOL SURVEY









I

I

I
1 The SWAL-QOL SURVEY


Quaity of Lifes
in Swallowig Disorder

























Instructions for Completing the SWAL-QOL Survey



This questionnaire is designed to find out how your swallowing problem has
been affecting your day-to-day quality of life.

Please take the time to carefully read and answer each question. Some
questions may look like others, but each one is different

Here's an example of how the questions in the survey will look.


1. In the last month how often have you experiences each of the symptoms below.


Thank you for your help in taking part in this survey!













r







l IMPORTANT NOTE: We jnrierstard thaL you may have a number of physical problems.
S Sonimime-re it is hard to separate these from swallowing difficulties, but we hope that you
can do your best to concentrate only on your swallowing problem. Thank you for your
i efforts in completing mrs questionnaire.


i 1. Below are some general statements that people with swallowing problems might
Mention In the last month, how true have the following statements been for you.

i(circle one number on each line)
Very much Quite a bit Somewhat A little Not at
true true true true all true
Dealing with my
swallowing problem is 1 2 3 4 5
very difficult.
I My swallowing problem is
a major distraction in my 1 2 3 4 5
life.___


2. Below are aspects of day-to-day eating that people with swallowing problems
sometimes talk about. In the last month, how true have the following statements
been for you?











a


m


* R
*I


j


3. Below are some physical problems that people with swallowing problems
sometimes experience. In the ;asit mintn how often you have experienced each
problem as a result of your swa3iowing problem?


Almost
always


ci're one numrnrr on eaPr -, n i
Often Sotmetimes Hardly
ever


Never


Couging 1 2 23 4
Choklin wen you eal tood 1 2 3 4 5
Choking when you take 1 2 3 5
liquids
Having tick sativa or phlegm 1 2 3 4 5
Gagging 1 2 3 5
Drooling 1 2 3 4 5
Problems chewing 1 2 3 4 5
Having excess saliva or 1 2 3 4 5
phlegm
Having to clear your throat 1 2 3 4 5
Food sticking in your throat 1 2 3 4 5
Food sticking in your mouth 1 2 3 4
Food or liquid dribbling out of
your mouth 1 2 3 4
Food or liquid coming out
yournose 1 2 3 4 5
Coughing food or liquid out ot
your mouth when it gets stuck 1 2 3 4 5

4. Next, please answer a few questions about how your swallowing problem has
affected your diet and eating in the last month.


















5, In the last rmonih, how often have the following statements about communication
applied to you because of your swallowing problem?


1 All of"
I the time


(circle one number on each line)
SMost of Some of A little of None of
the time the time the time the time


People hase a hard time
understanding me 1 3 4. 5
It s been difficult to r'ie to
speak clearly 1 2 3 4 5


6. Below are some concerns tnst people with swallowing problems sometimes
mention. In the last month, how often have you experienced each feeling?

(circle one number on each line)
Almost Often Sometimes Hardly Never
always ever
I fear I may sTart choking when I 1 2 3 4 5
eat food.
I worry about getting neumonia 1 2 ? 4 5
I am afraid of choking when 1 rink
Equids. 1 2 3 4 5
I never know when I am going to 1 2 3 4 5
choke.


7. In the last month, how often have the following statements been true for you because
of your swallowing problem?


F'


'' ------















34

Si


8. Think about your social life in the last month. How strongly would you agree or
disagree with the -o,'in.'r statements?


Strongly
agree


(circle one number on each line)
Agree | Uncertain Disagree


Strongly
disagree


I do nor g, oil to eal btecaulse 1 2 3 14
of my swallowing problem.
M, swallowing problem makes 1 2 ak 4
it nard to h3ve a social life
My usual work or leisure
activities have changed 1 2 3 4 5
because of my swallowing
problemrr
Social galaerlngs Ilikc holidays
or get-togethers) are not 1 2 3 4 5
enjoyable because of my
swallowing problem. __
My role withn Tmrly ard friends
has changed because of my 1 2 3 4 5
swallowing problem ___

9. In the last month, how often have you experienced each of the following physical
symptoms?

(circle one number on each line)
All of Most of Some of A little of None of
the time the time the time the time the time
Feel weak' 1 2 3 4 5
Have trouble failing asleep 1 1 2 2 4 5
Feel tired" 1 2 3 : 5
Have trouble staying asee. 1 2 4 5
Feel exhausteld 1 2 4 5


I









IN
ii




II


iI





























10 Do you now take any food or liquid .hro..gh a feeding tube?


(circle one)


No..............


. ... .... .. ...... .. 1


Yes.......................


11. Please circle the letter of the one description below that best describes the
consistency or texture of the food you have been eating most often in the last week.


Circle one:

A. Circle this one .i you are eating a full normal diet, which would include a wide
variety of foods, including hard to chew items like steak, carrots, bread, salad,
and popcorn.

8. Circle this one if you are eating soft, easy to chew foods like casseroles, canned
fruits, soft cooked vegetables, ground meat, or cream soups.

C. Circle this one if you are eating food that is put through a blender or food
processor or anything that is like pudding or pureed foods.

D. Circle this one if you take most of your nutrition by tube, but sometimes eat ice
cream, pudding, apple sauce, or other pleasure foods.

E. Circle this one if you take all of your nourishment through a tube,















I



J


12. Please circle the letter of the one description below that best describes the
consistency of liquids you have been drinl ing most often in the last week.


Circle one:

A. Circle this if you drink liquics such as water, milk, tea, fruit jirce and coffee.

B. Circle this if the majority of liquids you drink are thick, like tomato juice or apricot
nectar. Such thick liquids drip off your spoon in a slow steady stream when you
turn it upside down.

C. Circle this if your liquids are moderately thick like a thick milkshake or smoothie.
Such moderately thick liquids are difficult to suck through a straw, like a very
thick milkshake, or drip off your spoon slowly drop by drop when you turn it
upside down, such as honey.

D. Circle this if your liquids are very thick, like pudding. Such very thick liquids will
stick to a spoon when you turn it upside down, such as pudding.

E. Circle this if you did not take any liquids by mouth or if you have been limited to
ice chips.



13. In general, would you say your health is:


(circle one)


Poor ................................................


....... 1


Fair.....


... ....................................... ..... 3


Very Good.......... ........ ... .........

Excellent .................. ..................


.. ................ 4


......... .. ....................... 5


Good ................ ................


~



















General Quest


What is the date of your birth?

Please write in your date of birth here:


ions About You


/ monm
month (I y


What is your age today?


Are you -
(circle one)
Male ............ ...... ..... ...... ......... ..... ....... ...... ... 1

F em ale ....................... .................. .......................... ...... 2


What is your main racial or ethnic group?

(circle one)
White or Caucasian, but not Hispanic or Latino...... ................. 1

Black or African-American, but not Hispanic or Latino............................. 2

Hispanic or Latino ..................................... ........ 3

Asian................. ...... ......................... ... .................... 4

O ther................. .................. ........ ............... ............... 5



What is the highest year of school or college you have ever completed?

circle e one number)
1 1 2 3 1 5 6 7 1 8 9 10 11 1 12 13 14 15 16 16+
Grade Srni High Schoo Coallege Post
Graduate















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BIOGRAPHICAL SKETCH

Michelle Troche graduated with her Bachelor of Arts degree in communication

sciences and disorders and linguistics from the University of Florida in 2004. She

graduated summa cum laude and also received minors in teaching English as a second

language (TESL) and gerontology. She will complete the requirements for the Master of

Arts degree in speech pathology at the University of Florida as well. After graduation,

Michelle plans on pursuing a doctoral degree in speech pathology under the mentorship

of Christine Sapienza, specializing in motor speech disorders.




Full Text

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EFFECTS OF BOLUS CONSISTENCY ON TIMING AND SAFETY OF SWALLOW IN PARKINSONS DISEASE By MICHELLE S. TROCHE A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS UNIVERSITY OF FLORIDA 2006

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Copyright 2005 by Michelle S. Troche

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iii ACKNOWLEDGMENTS There are so many people who have provi ded me with support and encouragement throughout my journey thus far. I am abunda ntly grateful to God for placing each of those people in my path. I would especially like to thank my pare nts who have supported me in everything I have done until now. It is their love, guidance, and wisdom that have molded me into the person I am today. I must also thank my brother, Joshua, who not only provided his expert trajectory measurement skills to this project, but also keeps me grounded and sane on a daily basis. It is with much gratitude that I also thank my committee for their mentorship and guidance throughout this experience. I tha nk Dr. Christine Sapienza for providing me with so many amazing professional and edu cationally enri ching opportuniti es throughout the four years I have been under her mentor ship. Under her guidance, I have not only grown as a researcher, student, and clinician, but also as an indi vidual. I thank Dr. Rosenbek whose undying passion for all aspe cts of speech-language pathology (i.e., patient care, education, research) is truly insp irational. His example of using just the right amount of brains and just the right amount of heart in the care of patients is one I hope to follow. Lastly, I would like to thank my classm ates, labmates, and friends, especially Christina del Toro, whose ent husiasm and motivation were essential for the completion

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iv of this project and Karen Wheeler, who always made herself available to help, be it with statistics, answering questions, or just listeni ng to my theories. Many thanks to all.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 Background...................................................................................................................1 Significance and Hypotheses......................................................................................12 2 METHODS.................................................................................................................14 Participants.................................................................................................................14 Clinical Assessment of Parkinsons Disease Severity................................................15 Videoradiography.......................................................................................................16 Data Analysis..............................................................................................................18 Measurements Related to Swallow Timing.........................................................18 Measurements Related to Penetration/Aspiration...............................................19 Measurements of Hyoid Motion..........................................................................20 Measures of Quality of Life................................................................................21 Statistics..................................................................................................................... .22 Primary Aim........................................................................................................22 Exploratory Study................................................................................................22 3 RESULTS...................................................................................................................23 Primary Aim...............................................................................................................23 Reliability............................................................................................................24 Statistical Analysis..............................................................................................24 Exploratory Study: Hyoid Tr ajectory Measurements.................................................28 Reliability............................................................................................................28 Statistical Analysis..............................................................................................28 Case Studies.........................................................................................................30

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vi 4 DISCUSSION.............................................................................................................39 Primary Aim...............................................................................................................39 Measures of Bolus Transit...................................................................................39 Measures of Penetration/Aspiration....................................................................42 Quality of Life.....................................................................................................43 Exploratory Study.......................................................................................................44 Limitations and Strengths...........................................................................................47 Implications for Future Research................................................................................48 Implications for Swallow Intervention.......................................................................48 APPENDIX A UNIFIED PARKINSONS DISEASE RATING SCALE (UPDRS).........................50 B THE SWAL-QOL SURVEY......................................................................................56 BIOGRAPHICAL SKETCH.............................................................................................74

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vii LIST OF TABLES Table page 2-1 Participant Demographics........................................................................................15 2-2 Hoehn and Yahr Scale..............................................................................................16 2-3 Tags of bolus oral a nd pharyngeal transit times.......................................................18 2-4 Penetration-Aspiration Scale....................................................................................19 3-1 Mean values for the dependent variables.................................................................23 3-2 Pearson r correlation results for inter-rater reliability..............................................24 3-3 Results of the MANOVA.........................................................................................25 3-4 Results of the one-way analysis of variance (ANOVA)..........................................25 3-5 Means and standard deviations for de pendent variables as a function of bolus consistency...............................................................................................................26 3-6 Results of Pearson r correlati ons within the thin consistency..................................27 3-7 Results of Pearson r correlati ons within the thick consistency................................27 3-8. Intra-rater reliability for trajectory measurements....................................................28 3-9 Inter-rater reliability for trajectory measurements...................................................28 3-10 Means and standard deviations of de pendent measures as a function of bolus consistency...............................................................................................................28 3-11 Order of swallow events and hyoid trajec tory measurements for safe swallow...30 3-12 Order of swallow events and hyoid trajectory measurements for unsafe swallow...................................................................................................................31 3-13 Order of swallow events and hyoid trajec tory measurements for shorter swallow..34 3-14 Order of swallow events and hyoid traj ectory measurements for longer swallow..35

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viii LIST OF FIGURES Figure page 2-1 Example of fluoroscopic image from wh ere the measurements were completed....17 2-2 Figure depicting the refe rence line drawn from C3 to the hyoid prominence in frame one and a second line from a later frame.......................................................21 3-1 Figure depicting the change in averag e and max angle as a function of bolus consistency...............................................................................................................29 3-2 Figure depicting the change in averag e and max displacement as a function of bolus consistency......................................................................................................29 3-3 Figure depicting the change in average and max velocity as a function of bolus consistency...............................................................................................................30 3-4 Figure depicting the angle of the hyoid in degrees and the relationship to the defined swallow events in the “safe swallow”.........................................................31 3-5 Figure depicting the angle of the hyoid in degrees and the relationship to the defined swallow events in the “unsafe swallow”.....................................................32 3-6 Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallo w events in the “safe swallow”...........................32 3-7 Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallow events in the “unsafe swallow”.......................33 3-8 Figure depicting the hyoid traj ectory in the “safe swallow”....................................33 3-9 Figure depicting the hyoid traject ory in the “unsafe swallow”................................34 3-10 Figure depicting the angle of the hyoi d movement and the relationship to the defined swallow events in the shorter swallow........................................................35 3-11 Figure depicting the angle of the hyoi d movement and the relationship to the defined swallow events in the longer swallow.........................................................36 3-12 Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallow events in the shorter swallow..........................36

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ix 3-13 Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallo w events in the longer swallow...........................37 3-14 Figure depicting the hyoid traj ectory in the shorter swallow...................................37 3-15 Figure depicting the hyoid traj ectory in the longer swallow....................................38

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x Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Arts EFFECTS OF BOLUS CONSISTENCY ON TIMING AND SAFETY OF SWALLOW IN PARKINSONÂ’S DISEASE By Michelle S. Troche May 2006 Chair: Christine Sapienza Major Department: Communica tion Sciences and Disorders Safety and timing of swallow are essential for health and quality of life. The study of swallow in ParkinsonÂ’s disease (PD) is especially important in that aspiration pneumonia is the leading cause of death in this population. One of the therapeutic strategies employed in the treatment of sw allowing problems is diet modification. The primary aim of this study was to investigate the effects of bolus consistency on P-A score and timing of the oral-pharyngeal swallow of persons with PD. The secondary goal was to explore the relationship between various quantifiable components of hyoid movement and measures of swallow timing and penetr ation/aspiration. The videoradiographic images of ten participants with PD swa llowing six thin, and six pudding thick boluses were measured. The results demonstrat ed various significa nt differences and relationships among the dependent variables (i .e., oral transit time, pharyngeal transit time, number of tongue pumps, P-A score, a nd SWAL-QOL measures). The implications for further research and clin ical practice are discussed.

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1 CHAPTER 1 INTRODUCTION Background ParkinsonÂ’s disease (PD) is a neurologic condition characterized by impairment of the basal ganglia with death of dopaminergic neurons primar ily in the substantia nigra pars compacta (Brodal 1998; Marsden, 1984). Cardinal symptoms include skeletal muscle rigidity, akinesia (ina bility to initiate movement), hypokinesia (reduced range of movement with consequent ta rget undershooting), bradykine sia (slowness of movements once initiated), and resting tremor (Brodal, 1998; Hoehn & Yahr, 1967; Marsden, 1989). The above mentioned physiological changes aff ect the various muscle systems and cause changes at different levels of function. Of particular importance to this study, is the presence of changes in the bulbar system. One of the primary bulbar changes re ported by patients with PD is speech impairment. The speech of persons with PD, termed hypokinetic dysarthria, has been studied to great extent (i.e., Darley, Aronson, & Br own, 1969a; 1969b; Canter, 1963, 1965a, b). Although persons with hypokinetic dysarthria do not comprise a homogenous group, there are several predominant feat ures affecting many domains of speech including respiration, phonati on, articulation, resonance, and prosody (Darley et al., 1969a; 1969b). More specifically, speech associ ated with PD has been described as slurred (Doshay, 1960) and has been char acterized by monopitc h, reduced stress, monoloudness, imprecise consonants, variable rate, inappropriate pauses, short rushes, and a harsh, breathy voice (Darley et al ., 1969a, b; Canter, 1963, 1965a, b).

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2 Along with these predominant speech characte ristics, James Parkinson (1817) also reported changes in swallow function associated with the disease. In his first published description of PD, An Essay on the Shaking Palsy, he reported prepharyngeal abnormalities of ingestion, including difficulty initiating the swallow, maintaining selffeeding, impaired oral containment of both saliva and food, and labored lingual movements. His observations have proven quite accurate, but since ParkinsonÂ’s essay, much more research has been conducted in the area of normal swallowing function and swallowing dysfunction in various populati ons, including PD (i.e., Ardran & Kemp, 1951; 1956; 1967; Blonsky, Logemann, Bosh es, & Fisher, 1975, Bosma, 1957; Logemann, 1983). Swallowing is a complex process consisti ng of various pressure changes which successfully transport a bolus from the oral cav ity to the esophagus and into the stomach. The healthy swallow consists of four main phases: (1) the oral-preparatory phase, in which food is manipulated in the oral cavity; (2 ) the oral phase, at which time the tongue propels the bolus to the posterior aspect of the mouth and the swallow is triggered; (3) the pharyngeal phase, where the swallow is triggere d and the bolus is tr ansported through the pharynx, and (4) the esophageal phase at which time perist alsis transports the bolus through the esophagus and into the stomach (Logemann, 1983). The different phases of swallow are contro lled by various neural substrates. The oral-preparatory phase, which is considered to be volitionally cont rolled, is mediated by such cerebral structures as the cingulated cortex, insula, inferior frontal gyrus, supplementary motor area, sensorimotor cortex, supplementary sensory area, premotor cortex, antereolateral and posterior pari etal cortex, basal ganglia, thalamus, and

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3 cerebellum (Hamdy et al., 1996; Hamdy, Mikulis, Crawley, et al., 1999; Hamdy, Rothwell, Brooks, et al., 1999; Hamdy, Xue, Valdez, & Diamant, 2001; Martin, Goodyear, Gati, & Menon, 2001; Martin & Se ssle, 1993; Mosier et al., 1999; Zald & Pardo, 1999). Alternatively, it has been suggest ed that the pharyngeal phase of swallow, which is mainly considered reflexive, is cortically controlled by indirect pathways between extrapyramidal cortical motor planning regions and lower motor neurons (Huckabee, Deecke, Cannito, Gould, & Mayr, 2003). Persons with PD may experience changes in all the phases of swallow. It is uncertain which phase of the swallow is mo st impaired with the disease and what mechanisms are largely responsible for aspira tion. Ali et al. ( 1996) stated that the majority of patients with PD have dysphagi a related to the oral-pharyngeal phase of swallow, calling pharyngeal bolus transfer a “major determinant” of dysphagia in this population. Bassotti, Germani, Pagliaricci, Plesa, & Giuletti (1998), on the other hand, reported that esophageal motility was the most affected of the sw allowing functions. Interestingly, the vast majority of these st udies have been conduc ted utilizing only one consistency of bolus, which is difficult to gene ralize to the patients’ routine eating habits. More specifically, the stu dy of swallow function in those with PD indicates changes to the oral phase of swallow relating to bolus preparation and also indicate the presence of labial bolus leakage, deficien t or hesitant mastication, impaired lingual motility, lingual tremor, and slowed and limite d mandibular excursion, all of which affect the overall formation of the bolus (Ertekin et al., 2002: Leopold & Kagel, 1996). Oral transit time is also often sl owed in PD with changes including slow, repetitive lingual pumping, inability to properly propel the bolus posteriorly, prol onged lingual elevation,

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4 hesitancy in initiating the swallow, preswa llow spill, and piecemeal deglutition (Blonsky et al., 1975; Born, Harned, Ri kkers, Pfeiffer, & Quigley, 19 96; Coates& Bakheit, 1997; Ertekin et al., 2002: Leopold & Kagel, 1996). Consequently, post swallow residue in the oral cavity is often observed (Ali et al., 1996; Nagaya, Kachi, Yamada, & Igata, 1998; Stroudley & Walsh, 1991). Many changes also occur in the pharyngeal phase of swallow. Pharyngeal transit time is reported to be slow due to va rious symptoms causing dysfunction in the pharyngeal phase. Some of these changes incl ude abnormal or delayed contraction of the pharyngeal wall with subsequent coating of the walls (Ali et al., 1996), deficient epiglottic positioning, decreased epiglottic range of motion, stasis in the valleculae and/or pyriform sinuses (Blonsky et al., 1975; Er tekin et al., 2002; Le opold & Kagel, 1997), slow laryngeal elevation and excursion, aspiration, UES incoordination, as well as cricopharyngeal dysfunction (A li et al., 1996; Born et al ., 1996; Bushmann, Dobmeyer, Leeker, & Perlmutter, 1989; Coates & Bakheit, 1997; Eadie & Tyrer, 1964). Finally, changes in esophageal function which lead to prolonged transit times include decreased peristaltic motion, especia lly in the inferior third of the esophagus (Blonsky et al., 1975; Born et al., 1996), a nd delayed opening of the LES leading to gastro-esophageal reflux diseas e (Castell et al., 2001; Leopol d & Kagel, 1997; Nagaya et al., 1998; Stroudley & Walsh, 1991). The swallow mechanism as a whole is it self composed of many structures; the muscles of which are both of the striat ed and smooth type. The smooth muscle is controlled by the autonomic nervous system and may cause changes in esophageal and pharyngeal transit times due to motility ch anges evidenced by decreased peristalsis

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5 (Athlin, Norberg, Axelsson, Moller, & Nord strom, 1989; Lieberman et al., 1980). Changes due to the cardinal symptoms of PD are also observed in the swallow system with decline in motoric abilities due to ri gidity, hypokinesia, a nd tremor; processes controlled by dopaminergic pathways (Lieberman et al., 1980). Speci fically, rigidity and bradykinesia are likely responsib le for difficulty chewing and drooling of saliva. Eadier & Tyrer (1965) and Ertekin et al. (2002) hypothesized that the hypoki netic, reduced rate of spontaneous swallowing movements, and th e “slowness of segmented but coordinated sequential movements” a problem seen in ot her motor systems in PD, may be the most significant cause of swallow dysfunction in PD. It is interesting to note, that often times patients with PD demonstrate greater impair ment of voluntary task s versus involuntary tasks (Yamaguchi & Kabayashi, 1998). Th is is important to the understanding of swallow dysfunction in PD due to the voluntary nature of the oral phase of swallow, and the involuntary nature of th e pharyngeal phase of swallow. In addition to the abovementioned mechanistic impairments, it has b een reported that swallow dysfunction in PD may be secondary to impairment of other mechanisms including autonomic processes, perception, cognition, and emoti on (Athlin et al., 1989). Severity and degree of motor involvement in PD do not necessarily correlate with severity of swallow dysfunction, making the timeline of swallow changes difficult to predict (Ali et al., 1996). Si milarly, clinical staging does not predict swallow difficulty (Bushmann et al., 1989). For instance, the literature suggests that the Unified Parkinson Disease Rating Scale (UPDRS; Fahn, Marsden, Calne, & Goldstein, 1987), which is used to assess severity of the disease, does not predict swallowing dysfuncti on. In fact, Ali et al. (1996) found no relation between limb tr emor and lingual tremor and no relation

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6 between muscular rigidity and dysmotility of the pharyngeal wall. The poor correlation between swallowing dysfunction and diseas e severity rating, along with patient complaints of swallow problems and findings on videofluoroscopic examinations makes swallow assessment and subsequent treatment in PD a difficult task (Bushmann et al., 1989). Currently the primary treatment for PD is Levodopa (L-Dopa). L-Dopa has been found to be efficacious for the treatment of the primary clinical features of the PD syndrome (Calne, Shaw, Spiers, & Stern, 1970) The same results have not been observed consistently in the treatment of dysphagia in PD (Born et al., 1996; Hunter, Crameri, Austin, Woodward, & Hughes, 1997; Leopold & Kagel, 1997). Nilson, Ekberg, Olsson, & Hindfelt (1996) assert that oral and pharyng eal function in PD are not the result of reduced dopamine levels, therefore L-Dopa is ineffective. On the other hand, Bushmann et al. (1989) found less vallecula r residue and decrea sed coating of the pharyngeal walls post treatment with L-dopa The strongest theory as to the ineffectiveness of dopaminergic medications in PD swallow is the dual involvement of muscle tissue described previ ously. Therefore treatment fo r swallow dysfunction in PD cannot be treated solely with medical in terventions, but instead by compensatory strategies and dietary modifications. Dysfunction in swallow, also called dyspha gia, can lead to many life-threatening problems such as dehydration, malnutrition, weig ht loss, aspiration of solids and liquids, and pneumonia (Bushmann et al., 1989; Raut, McKee, & Johnston, 2001). A timely and safe swallow, is essential to health and quali ty of life. Assessment of swallow safety and treatment of swallowing disorders is an integr al part of a speech-language pathologistÂ’s

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7 scope of practice. Unfortunately, there are no clear cut guidelines regarding the amount of aspiration which can occur in a specific patient before the patient is at severe risk for pneumonia. Actually, physicians show vari ance in their tolerance for aspiration in patients, with some tolerating only small amounts of aspiration, and others more. In addition, of concern is whether or not the pa tient is healthy enough to combat a severe infection like pneumonia; therefor e, aspiration is kept to a mi nimum in order to avoid any complications. Logemann (1983) suggests that health, mobility, cognition, frequency of aspiration, and type of material aspirated all influence the bod yÂ’s response to aspiration and penetration. Rosenbek, Robbins, Roecker Coyle, & Wood (1996) suggest that the amount of aspiration, the extent to which the material passes into the airway, and the ability of the person to expel the materi al are also crucial. Logemann (1983) recommends that any patient who aspirates at least 10% of boluses of a specific consistency, even following use of maneuve rs and compensatory strategies, should eliminate or restrict their oral consump tion of boluses of said consistency. Currently, the most effective method of determining presence and degree of aspiration is videoradiogra phic evaluation; unfortunately though, this method cannot elucidate the amount of aspiration a person can tolerate before pneumonia develops and possible death ensues. There are few scales which actually quantify the swallow impairment. The Penetration-Aspiration Sc ale (P-A Scale; Rosenbek et al., 1996) is currently the most reliable measure. This ordinal measurement describes whether or not the bolus has entered the airw ay, the degree to which it ha s entered the airway, whether there is any residue, and whether the person tr ied to expel the material or not.

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8 Although it has often been considered a featur e of late stage PD (Lieberman et al., 1980), dysphagia has also been reported in earl y stages of PD (Ali et al., 1996; Coates & Bakheit, 1997; Stroudley & Walsh, 1991) and as a presenting symp tom of the disease (Croxson & Pye, 1988). These changes are of ma rked concern due to its association with considerable morbidity from nutritional a nd pulmonary compromise (Ali et al., 1996; Bassotti et al., 1998; Coates & Bakheit, 1997), as well as the possibility of death (Kirshner, 1997; Stroudley & Walsh, 1991). In fact, aspiration pneum onia is the leading cause of death in PD (Fernandez & Lapa ne, 2002; Gorell, Johnson, & Rybicki, 1994; Hoehn & Yahr, 1967; Schiermier, Schafer, Sc hafer, Greulich, & Schlafke, 2001; Shill & Stacy, 1998; Singer, 1992). The incidence of dysphagia in persons with PD is hard to define, with evidence of swallow dysfunction reported between 18.5% to 100% of the patients studied (Ali et al., 1996; Bassotti et al., 1998; Coates & Bakhe it, 1997; Hunter et al., 1997; Logemann, Blonsky, & Boshes, 1975; Stroudley & Wals h, 1991), depending on the criteria and instrumentation used to diagnose dysphagia and the participant popul ation selected. In comparison, studies assessing patientsÂ’ awar eness of dysphagia have found only 15-50% of these patients demonstrating signs of swallow dysfunction complain of dysphagia, compared to 6-12% in age matched adults (Born et al., 1996; Loge mann et al., 1975). Therefore, many patients with PD are unawa re of their swallowing dysfunction. In addition, studies have found that as many as 15% of patients with PD who do not complain of dysphagia do not recognize they are aspirating, termed silent aspiration (Ali et al., 1996). It is this as piration, in conjunction with a decreased cough strength and

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9 delayed cough reflex, which pla ces patients with PD at significant risk for complications related to swallow dysfunction (Ertekin et al., 2002; Hunter et al., 1997). Swallow timing, although less critical to he alth than swallow sa fety, has significant implications for quality of life. As described above, persons with PD often develop dysphagia early on in the diseas e process with tongue pumping ar ising as one of the first symptoms. This tongue pump can cause in creased oral transit times and therefore increased eating time for the patient. Th ese changes may have social or personal repercussions which affect th e personÂ’s quality of life. In order to aid the swallow function in patient populations, swallow therapy strategies have been developed by clinicia ns. Swallowing maneuvers and other similar compensatory strategies, although valuable in many populations, may be less beneficial in the PD population which often has difficultie s with cognition, including an inability to maintain and shift sets, and problems with th e coordination of comple x tasks (i.e., Bayles, 1990; Cooper et al., 1991). Th is is significant because ma ny compensatory strategies used for swallow are often multi-step, comp lex motor movements. Such maneuvers include the supraglottic swallow in which the patient is instructed to take a breath and hold it while swallowing and then cough afte r the swallow, and the super-supraglottic swallow, the instructions of which are the same as above, but the pati ent is instructed to bear down while holding their breath (Martin, Logemann, Shaker, & Dodds, 1993; Mendelsohn, & Martin, 1993; Ohmae, Loge mann, Kaiser, Hanson, & Kahrilas, 1995; Ohmae, Logemann, Kaiser, Hanson, & Kahrilas 1996). Others include maneuvers such as the Mendelssohn (Jacob, Kahrilas, Loge mann, Shah, & Ha, 1989; Kahrilas, Dodds, Dent, Logemann, & Shaker, 1988; Kahrilas, Logemann, Krugler, & Flanagan, 1991;

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10 Lazarus, Logemann, & Gibbons, 1993; Logema nn & Kahrilas, 1990) and Effortful swallow (Bulow, Olsson, & Ekberg, 1999; Hi nd, Nicosia, Roeker, Carnes, & Robbins, 2001; Lazarus, Logemann, Song, Rademaker, & Kahrilas, 2002; Pouderoux & Kahrilas, 1995), where patients are asked to keep the larynx elevated for several seconds after the swallow, and to swallow hard tightening th e throat and neck muscles, respectively (Logemann, 1983). The complex nature of these tasks, in conjunction with the cognitive and working memory impairments often presen t, leave few options for the treatment of swallowing disorders in persons with PD. This is of partic ular concern in that swallow dysfunction can initiate in the early stages of PD, as can cognitive changes. Dietary modifications may be most bene ficial in this population. Generalization and maintenance of mane uver and compensatory strategy use outside of the clinic may be compromised by possible anosognosia, or unawareness of deficits associated with illn ess, in patients with PD. Although little research has been conducted in the area of anosgnosia in PD, Starkstein et al. (1996) and Seltzer Vasterling, Mathias, & Brennan (2001) found that patients with PD did demonstrate some anosognosic symptoms, although not as severe as those observed in Alzheimer’s disease. Clinically, it seems that the symp toms observed in patients with PD can more accurately be described as a problem of “insi ght.” Often times patients with PD require much more cueing during and before tasks in order for the tasks to be completed accurately and appropriately, this may be a function of both working memory dysfunction and “insight” defici ts, impeding the patient from completing the tasks to their maximum performance. It is these problems of generalization and maintenance, coupled

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11 with the challenge of learning the often complex maneuvers, th at may make this type of swallow therapy a real challenge in this population. Dietary modifications as a treatment strategy for oral-pharyngeal dysphagia normally consist of thickening liquids or r ecommending puree consistency foods (Raut et al., 2001). Although there is res earch investigating the effects of consistency on swallow in healthy adults, healthy older adults, and persons with dysphagia caused by stroke and other neurological conditions, c onsistency differences related to swallow function in PD has not been adequately studied. In terms of diet modification, thicker liq uids have been used based on the theory that perhaps the thickened liqui d stimulates the pharynx to co ntract harder and longer in order to protect the airway more adequately (Raut et al ., 2001). Research involving healthy ageing persons and others with dyspha gia secondary to str oke reports results demonstrating that as a liquid becomes more viscous duration of tongue base posterior pharyngeal wall contact increa ses, oral-pharyngeal transi t time increases, pharyngeal delay times decrease, duration of peristalti c waves are longer, and average EMG activity is increased (Ding, Logemann, Larson, & Rademaker, 2003; Kendall, Leonard, & McKenzie, 2001; Kuhlemeier, Pa lmer, & Rosenberg, 2001). Incr eases in oral-pharyngeal pressures and velocities are n eeded in order to propel the bolus into the pharynx (Hiss, Strauss, Treole, Stuart & Boutilier, 2004). Research has also focused greatly on the movement of the hyoid bone during swallowing of differing consistencies in he althy normal controls and persons with neurological impairment (not including PD), with some controversy. Some of the literature shows that thicke r boluses can lead to great er hyoid displacements and

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12 subsequently higher magnitudes of laryngeal movement, but shorter laryngeal elevation durations (Dantas & Dodds, 1990; Dantas, D odds, Massey, & Kern, 1989; Ertekin et al., 1997), yet other researchers ha ve found just the opposite (Bisch, Logemann, Rademaker, Kahrilias, & Lazarus, 1994; Ekberg, Lie dberg, Owall, 1986; Perlman, Vandaele, & Otterbacker, 1995). Nonetheless, research using EMG has consistently found a positive relationship between bolus viscosity and activation magnitude and duration of the suprahyoid and infrahyoid muscles (Dantas & Dodds, 1990; Palmer, Luschei, Jaffe, & McCulloch, 1999). Significance and Hypotheses There are many unanswered questions related to the effects of bolus consistency on the oral and pharyngeal phases of swallow in PD. Of more c oncern, is the fact that these variables have not been described in relationship to the swallow timing and penetration/aspiration, which are bo th factors essential to health and quality of life in this population which has a high incidence of dysphagia and aspiration pneumonia (often resulting in death). To the researcherÂ’s knowledge, no we ll-controlled study has ever looked at both the oral and pharyngeal phases of swallow as related to bolus consistency in the same group of participants with PD, with special attention to swallow timing and penetration/aspiration; a topic of great clin ical significance. The primary aim of this study is to investigate the eff ects of bolus consistency on the P-A score and timing of the oral-pharyngeal swallow of persons with PD The secondary goal of this study is to explore the relationship between the various quantifiable component s of hyoid movement and measures of swallow timing and penetration/aspiration. The following questions and hypothese s were developed for study:

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13 1. What are the effects of bolus consistency on the timing of swallow in persons with PD as measured by oral and pharyngeal tran sit times and number of tongue pumps? It was hypothesized that both oral and pharyngeal tr ansit times would increase with thicker consistencies versus thinner c onsistencies. It was also hypothesized that oral transit time woul d be increased to a greater degree across the consistency condition and that the number of tongue pumps would increase significantly with thicker consistencies. 2. What are the effects of bolus consiste ncy on Penetration-Aspiration Scale in persons with PD? It was hypothesized that P-A scale values would decrease with thicker consistencies, than thinner consistencies, indicating increased safety of swallow. 3. Is there a relationship between timing and penetration/aspiration within the thick and thin consistency conditions? It was hypothesized that there would be a significant negativ e correlation between oral and pharyngeal transit times and PA scale values for the thick and thin consistencies. 4. Do the distinct changes evidenced in the swallow of persons w ith PD translate to changes in quality of life as measured by the SWAL-QOL? It was hypothesized that persons with more impaired oral stages of swallow would report more impaired quality of life.

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14 CHAPTER 2 METHODS Participants Ten (5 male; 5 female; mean age 68.5 years; Table 2-1) participan ts with idiopathic Parkinson’s disease (PD) were recruited from the University of Florida (UF) and Malcom Randall Veterans Affairs (VA) Medical Ce nter Movement Disorders Clinics in Gainesville, Florida. All participants were on one or more anti-Parkinsonian medications (i.e., Levodopa/Carbidopa, Selegeline, Amantadine etc). Inclusionary criteria included: 1) age between 35-80 years; 2) diagnosis of idiopathic Parkinson’s disease by a movement disorders neurologist; 3) moderate clinical disability level (IIIII; Hoehn & Yahr, 1967); and 4) score of at least 24 on the MiniMental State Examination (Folst ein, Folstein, & McHugh, 1975). Exclusionary criteria include d: 1) other neurological diso rders; 2) gastrointestinal disease; 3) gastro-esophageal surgery; 4) h ead and neck cancer; 5) history of breathing disorders or diseases; 6) untreated hypertension; 7) heart disease; 8) history of smoking in the last five years; 9) faili ng the screening test of pulmonary functions; and 10) difficulty complying due to neuropsychological dysfunction (i.e., se vere depression). Once patients were screened for inclusionary and exclusionary cr iteria, participants gave written consent and were subseque ntly enrolled in th e study. The study was approved by the UF and VA Institutional Review Boards (154-2003). Participants were all “on” PD medications when the testing was conducted. They were tested one-hour after medications were taken in order to help ensure measur es were completed at optimal

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15 medication activity (Nutt, 1987). In addition, al l participants reporte d feeling “on” their medications, and none of the patients showed signs of dyskinesias. Table 2-1. Participant Demographics Participant No. Gender Age H & Y 1 F 56 2 2 F 74 2 3 M 71 2 4 M 73 2 5 M 76 2 6 M 77 2 7 M 56 2 8 F 76 3 9 F 63 2 10 F 63 2 Clinical Assessment of Park inson’s Disease Severity Each patient underwent a clinical assessment of Parkinson’s disease severity. This assessment was completed by a UF Movement Disorders neurologist. Severity was measured using the Unified Parkinson’s Dis ease Rating Scale (UPDRS ; Fahn et al., 1987; Appendix A) and Hoehn & Yahr Scale (1967 ; Table 2-2). The UPDRS quantifies the primary and secondary motor symptoms of a person with PD by assessing cognition, ability to perform activities, mentation, activities of daily liv ing, and neurological examination. For the purposes of this clinical assessment, only the motor exam portion (III) of the UPDRS was utilized. The Hoehn & Yahr scale is based on five stages, and is an objective measure used to grade presen ce of tremor, rigidity, bradykinesia, and postural instability.

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16 Table 2-2. Hoehn a nd Yahr Scale (1967) Stage Characteristics 1 Signs and symptoms on one side only Symptoms mild Symptoms inconvenient, but not disabling Usually present with tremor of one limb Friends have noticed changes in postu re, locomotion, and facial expression 2 Symptoms are bilateral Minimal disability Posture and gait affected 3 Significant slowing of body movements Early impairment of equilib rium on walking or standing Generalized dysfunction that is moderately severe 4 Severe symptoms Can still walk to a limited extent Rigidity and bradykinesia No longer able to live alone Tremor may be less than earlier stages 5 Chachectic stage Invalidism complete Cannot stand or walk Requires constant nursing care Videoradiography Swallowing function was visualized and st udied using videofluoroscopy. Patients were seated upright and images of barium swallows were recorded in the lateral view. A penny was placed behind the ear in order to have a referent of known length for later displacement measurements. In addition, a headband with a hanging copper-lined triangle (i.e., Chi-Fishman & Sonies, 2000) was in place controlling for head posture changes and facilitating later di splacement measures (Figure 21). A properly collimated Phillips Radiographic/Fluoroscopic unit that provides a 63-kV, 1.2-m-A type output for full field of view mode was used. Fluor oscopic images were recorded to a Kay Elemetrics Swallowing Signals Lab (Kay Elem etrics, Lincoln Park, NJ) using a digital scan converter and were electronically recorded at 30 frames per second.

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17 Included in the field of view, at the very least, were the lips and teeth anteriorly, nasal spine superiorly, cerv ical spine posteriorly, a nd upper esophageal sphincter inferiorly, allowing for a complete visualizat ion of the oral and pharyngeal structures involved in swallow, specifica lly those needed for the meas urements completed for this protocol: the tongue, ramus of the mandible, hyoid bone, and upper esophageal sphincter. Figure 2-1. Example of Fluoroscopic imag e from where the measurements were completed. Note penny and copper triangle headband for measurement purposes. Participants completed a dry swallow, six 5 cc. trials of pudding thick liquid (Varibar Pudding-Barium Sulfate Esophageal Paste 230 mL 40% w/v, 30% w/w from EZ-EM) in a spoon, and six 5 cc trials of thin liquid (Liquid E-Z Paque Barium Sulfate Suspension; 60% w/v, 41% w/w; from E-Z-EM) in a cup. Trials were presented in random order, in order to control for fatigue and other effects relate d to order of bolus presentation. In order to approximate the ev eryday feeding conditions of the patient, the cup and spoon were utilized; a ll the patients fed themselves in the home, therefore they

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18 self-fed during all trials. Patients were given the spoon or cup and prompted by the clinical researcher to “place the liquid in your mouth and swallow when you are ready.” Data Analysis Measurements Related to Swallow Timing Measurements of bolus transit were co mpleted by analyzing the recordings of swallow trials frame-by-frame or in slow-m otion using the Kay Swallow station. The measurements were completed by an examiner tr ained in the analysis of modified barium swallow studies. The examiner was blinded to the patients’ identity. Tags were placed at various swallow events in order to facilitate measurement. The swallow events measured are explained in detail in Ta ble 2-3. These measurements were selected in order to capture the effects of bolus consistency on the timing of the swallow in persons with PD. Using these events, measurements of oral a nd pharyngeal transit times were completed. Table 2-3. Tags of bolus oral and pharyngeal transit times Onset of Oral Transit Time Onset of posterior movement by the bolus in the oral cavity Point at which the tongue tip is raised and the bolus begins posterior movement towards the posterior aspect of the oral cavity. Offset of Oral Transit Time Point at which the tail of the bolus passes the level of the ramus of the mandible Onset of Pharyngeal Transit Time Point at which the leading edge of the bolus passes the level of the ramus of the mandible. Offset of Pharyngeal Transit Time Poin t at which the tail of the bolus passes through the upper esophageal sphincter (UES). Number of tongue pumps Number of times the tongue pumps (rocks) while the bolus is in the oral cavity, resulting in the posterior movement of the bolus and the initiation of the swallow reflex.

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19 Measurements Related to Penetration/Aspiration In order to assess the penetr ation/aspiration of swallows of different consistencies, the Penetration-Aspiration Scale (P-A Scale; Rosenbek et al., 1996; Table 2-4) was used to rate each swallow. The P-A Scale is used to measure whether or not material entered the airway and if it did, wh ether the residue remained or was expelled. These measurements were also completed using fram e-by-frame analysis by an expert rater who was blinded to the participantÂ’s identity. Table 2-4. Penetratio n-Aspiration Scale 1 Contrast does not enter the airway No Penetration/Aspiration 2 Contrast enters the airway, remains above the vocal folds Penetration 3 Contrast remains above the vocal folds with visible residue Penetration 4 Contrast contacts vocal folds, no residue Penetration 5 Contrast contacts vocal folds, visible residue Penetration 6 Contrast passes glottis, no subglottic residue Aspiration 7 Contrast passes glottis, visible sub-glottic residue despite patient response Aspiration 8 Contrast passes glottis, visible sub-glottic residue, absent of patient response Aspiration (Rosenbek et al., 1996)

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20 Measurements of Hyoid Motion In order to better assess the function of the hyoid bone, trajectory measurements were completed. These measurements are used to determine the hyoid anterior and superior pattern of excursion and depict the pattern of move ment as related to the bolus location. The data was collected from two randomly selected swallows of six (three men, three women) of the previous ten participants. The measurements were completed by an expert rater with experience measuring hyoid tr ajectories. In order to complete these measures, using dpsReality Video Editor, the JPG images for each frame of the individual swallows were extracted. The im ages extracted were those between the point when the bolus first began its posterior m ovement and the point when the bolus tail entered the UES. These images were then imported and analyzed using a Matlab 7.0.1 routine (Wheeler, Martin-Harris, Bronsky, & Sapienza, 2006), which was developed at the University of Florida. The imported files were then presented in random order to the measurer. The measurer picked two points in each frame. On e point was the anterior most portion of C3 and the other the anterior portion of the hyoid bone. Once this was completed, the program presented the frames in sequentia l order and the rater tagged the various swallow events which were chosen for analysis In this study the swallow events chosen were: 1) onset of bolus posterior movement, 2) point when the bolus head arrived at the level of the ramus of the mandible, 3) point when the palate first made contact with the posterior pharyngeal wall, 4) point of maximu m laryngeal elevation, 5) point at which the bolus entered the UES, 6) point at which the UES closed, following the passing of the bolus, and 7) point when the palate lowere d from the palate. Once the analysis was

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21 complete, the program provided a figure depicting the motion of the hyoid bone, a spreadsheet with the angle and displacem ent measures, and figures representing displacement and angle in pixels and millim eters. The program obtains the angle measurements from a reference line drawn from the anterior portion of C3 to the anterior prominence of the hyoid bone in frame one (Fi gure 3-2). The displacement measures are also obtained using C3 as a referent. Th e use of the penny marker, allows for the translation of pixel measurements to actual millimeters. Figure 2-2. Figure depicting th e reference line drawn from C3 to the hyoid prominence in frame one and a second line from a later frame. Measures of Quality of Life In addition, the patientsÂ’ quality of li fe as related to swallow function was measured using a perceptual self-rating scal e, Swallowing Quality of Life Questionnaire (SWAL-QOL; McHorney, Bricker, Kramer, et al., 2000; McHorney, Bricker, Robbins, et al., 2000; McHorney et al., 2002; Appendix B). This tool includes questions regarding both the oral and pharyngeal phases of swallo w as well as appetite eating duration, and other factors affecting swallow function. Completing these measures allows for the assessment of personsÂ’ awareness of their swallowing deficits. C3

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22 Statistics Primary Aim A one way analysis of variance was used to assess the effect of bolus consistency on the dependent measures (i.e., oral transit, pharyngeal transit, number of tongue pumps, P-A score). Pearson r correlations were used to assess th e relationships of the dependent variables within consistencies. Lastly, descriptive statistics were used to identify outliers and questions for further study. Exploratory Study Due to the small sample size in this pilot pr oject, descriptive statistics together with scatter plots and visual analysis of out put from the MATLAB program were used to identify trends, outliers, and evidence for formulation of further research questions.

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23 CHAPTER 3 RESULTS Primary Aim Hypotheses 1-4 were tested by co mpleting measures of timing and penetration/aspiration on six thin consistenc y and six thick consistency swallows in ten patients (5 male, and 5 female) with PD. Th e mean data for each dependent variable are presented below in Table 3-1. Table 3-1. Mean values for the dependent va riables (for consistency, 1=thin, 2=thick). Subj No. Consistency OTT PTT Tongue Pumps PA Scale Swalqol 1 1 1.527 1.561 1.000 1.333 176 1 2 4.433 2.389 6.833 1.000 2 1 0.945 0.889 0.167 3.333 208 2 2 5.533 3.139 3.667 1.333 3 1 1.374 0.823 2.000 1.667 211 3 2 2.931 1.716 4.000 1.000 4 1 0.553 0.656 0.167 2.833 207 4 2 1.079 0.959 0.667 1.000 5 1 0.729 0.998 0.167 1.167 204 5 2 1.187 0.623 0.833 1.000 6 1 0.295 0.489 0.500 1.500 138 6 2 1.254 0.470 1.000 1.167 7 1 1.193 0.642 0.167 1.333 156 7 2 1.604 0.612 0.500 1.000 8 1 1.146 0.842 0.167 1.000 193 8 2 2.261 1.269 2.333 1.000 9 1 0.361 0.762 0.000 1.000 211 9 2 2.475 0.548 3.833 1.000 10 1 1.035 0.646 0.000 4.000 212 10 2 1.182 0.642 1.833 1.167

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24 Reliability Pearson r correlations were conducted in order to assess inter-rate r reliability for measures of swallow timing and penetration/ aspiration. All measures were found to be reliable at p 0.05 showing moderate to strong correlati ons between the ra tings of the two measurers (Table 3-2). Table 3-2. Pearson r correlation resu lts for inter-rater reliability. Dependent Variable Pearson r coefficient Alpha Oral transit time .989** .000 Pharyngeal transit time .883** .000 No. of Tongue Pumps .759** .004 P-A Score .674* .016 *correlation is sign ificant at the 0.05 level (two-tailed). **correlation is significant at the 0.01 level (two-tailed) Statistical Analysis A multivariate analysis of variance (M ANOVA) with covariates of gender and consistency was completed in order to determin e if there were any significant effects of gender or interactions between gender and c onsistency on the dependent measures. The MANOVA showed no significance for gender (T able 3-3). Significance level was set at 0.05. Therefore, a one-way analysis of vari ance (ANOVA) was used to analyze the results of the dependent variab les (oral transit time, pharynge al transit time, number of tongue pumps, and P-A Scale) as a function of bolus consistency (i.e., thin vs. pudding thick). Results of this ANOVA (presented in Table 3-4) revealed significant differences (p 0.02) between oral transit time (p=0.008), number of tongue pumps (p=0.005), and P-

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25 A scale (p=0.023) with bolus consistency. No significant difference was found for pharyngeal transit time (p=0.196) as a function of bolus consistency Table 3-3. Results of the MANOVA. Multivariate Testsb .894 27.360a 4.000 13.000 .000 .106 27.360a 4.000 13.000 .000 8.419 27.360a 4.000 13.000 .000 8.419 27.360a 4.000 13.000 .000 .221 .922a 4.000 13.000 .481 .779 .922a 4.000 13.000 .481 .284 .922a 4.000 13.000 .481 .284 .922a 4.000 13.000 .481 .688 7.160a 4.000 13.000 .003 .312 7.160a 4.000 13.000 .003 2.203 7.160a 4.000 13.000 .003 2.203 7.160a 4.000 13.000 .003 .291 1.332a 4.000 13.000 .310 .709 1.332a 4.000 13.000 .310 .410 1.332a 4.000 13.000 .310 .410 1.332a 4.000 13.000 .310 Pillai's Trace Wilks' Lambda Hotelling's Trace Roy's Largest Root Pillai's Trace Wilks' Lambda Hotelling's Trace Roy's Largest Root Pillai's Trace Wilks' Lambda Hotelling's Trace Roy's Largest Root Pillai's Trace Wilks' Lambda Hotelling's Trace Roy's Largest Root Effect Intercept GENDER CONSIST GENDER CONSIST Value F Hypothesis df Error df Sig. Exact statistic a. Design: Intercept+GENDER+ CONSIST+GENDER CONSIST b. Table 3-4. Results of the one-way analysis of variance (ANOVA). ANOVA 10.924 1 10.924 8.743 .008 22.490 18 1.249 33.414 19 .824 1 .824 1.803 .196 8.224 18 .457 9.048 19 22.396 1 22.396 9.951 .005 40.511 18 2.251 62.906 19 3.612 1 3.612 6.210 .023 10.468 18 .582 14.080 19 Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Between Groups Within Groups Total Oral Transit Time Pharyngeal Transit Time Tongue Pumps PA Scale Sum of Squares df Mean Square F Sig. Table 3-5 presents the mean data for each of the dependent variables for the thin and thick consistencies. Oral transit time was longer with the pudding thick consistency than the thin consistency. The number of tongue pumps increased with the pudding thick

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26 consistency, than the thin consistency. P-A score was lower with the pudding thick consistency than the thin consistency. Table 3-5. Means and standard deviations for dependent vari ables as a function of bolus consistency. Thin Thick Dependent Variable Mean St Dev Mean St Dev Oral Transit Time 0.916 0.420 2.394 1.524 Pharyngeal Transit Time 0.831 0.296 1.237 0.909 Number of Tongue Pumps 0.433 0.625 2.550 2.028 P-A Scale 1.917 1.072 1.067 0.117 The third hypothesis was that there woul d be a significant negative correlation between oral and pharyngeal transit times a nd P-A scale values for the thick and thin consistencies. The fourth hypothesis was that persons with more impaired oral stages of swallow would report more im paired quality of life. A Pearson r correlation was conducted in order to assess the relationshi p between the various dependent measures within each bolus consistenc y. Results of the Pearson r correlation are presented in Tables 3-6 and 3-7. There were no signi ficant correlations be tween the dependent measures within the thin consistency. Various significant relationships were identified within the thick consistency boluses. For the thick consistency, significant positive relationships (p< 0.05) were found between oral transit and pharyngeal transit times (p=.000, r=.939), number of tongue pumps and oral transit (p=.007, r=.789) and tongue pumps a nd pharyngeal transit time (p=.029, r=.683). No significant re lationship was found between any of the dependent measures and swallow quality of life or P-A score in either of the consistencies.

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27 Table 3-6. Results of Pearson r correl ations within the thin consistency. Correlations 1 .586 .515 .005 .074 .075 .128 .989 .840 10 10 10 10 10 .586 1 .314 -.248 .125 .075 .376 .490 .731 10 10 10 10 10 .515 .314 1 -.212 -.013 .128 .376 .557 .971 10 10 10 10 10 .005 -.248 -.212 1 .390 .989 .490 .557 .265 10 10 10 10 10 .074 .125 -.013 .390 1 .840 .731 .971 .265 10 10 10 10 10 Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Oral Transit Time Pharyngeal Transit Time Tongue Pumps PA Scale Swal-qol Oral Transit Time Pharyngeal Transit Time Tongue Pumps PA Scale Swal-qol Table 3-7. Results of Pearson r correlat ions within the thick consistency. Correlations 1 .939** .789** .408 .169 .000 .007 .241 .642 10 10 10 10 10 .939** 1 .683* .426 .226 .000 .029 .220 .531 10 10 10 10 10 .789** .683* 1 -.003 .199 .007 .029 .993 .582 10 10 10 10 10 .408 .426 -.003 1 -.003 .241 .220 .993 .993 10 10 10 10 10 .169 .226 .199 -.003 1 .642 .531 .582 .993 10 10 10 10 10 Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Pearson Correlation Sig. (2-tailed) N Oral Transit Time Pharyngeal Transit Time Tongue Pumps PA Scale Swal-qol Oral Transit Time Pharyngeal Transit Time Tongue Pumps PA Scale Swal-qol Correlation is significant at the 0.01 level (2-tailed). **. Correlation is significant at the 0.05 level (2-tailed). *.

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28 Exploratory Study: Hyoid Trajectory Measurements Reliability Recent investigations have found that th e University of Florida hyoid trajectory program measurements are highly reliable. A recent study by Wheeler et al. (2006), found both intra and inter-ra ter reliability to be high (Tables 3-8 & 3-9). Table 3-8. Intra-rater reliability for trajectory measurements Dependent Variable Pearson r coefficient Alpha value Average Angle .942 .000 Average Displ .823 .001 Max Angle .945 .000 Max Displacement .872 .000 Table 3-9. Inter-rater reliability for trajectory measurements Dependent Variable Pearson r coefficient Alpha value Average Angle .975 .000 Average Displ .895 .003 Max Angle .966 .000 Max Displacement .793 .019 Statistical Analysis Due to the nature of this pilot work, (i.e., small n, no data norms) mainly descriptive statistics (Table 3-10) were used in order to identify any possible preliminary effects. Table 3-10. Means and standard deviations of dependent measures as a function of bolus consistency. Thin Thick Dependent Variables Mean St Dev Mean St Dev Average Angle 4.64 1.67 6.19 3.50 Max Angle 10.95 3.50 15.17 4.85 Average Displacement 3.41 2.58 3.11 2.26 Max Displacement 11.53 3.92 13.60 3.52 Average Velocity 43.56 11.06 46.33 15.99 Max Velocity 154.00 45.99 161.20 47.28

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29 The means of all, except one of the de pendent measures were higher with the thicker consistency (Figure 3-1 –3-3). The only dependent measure where this trend was not observed was average displacement (Figure 3-2). 0.0000 2.0000 4.0000 6.0000 8.0000 10.0000 12.0000 14.0000 16.0000 ThinThickAngle (degrees) Average Angle Max Angle Figure 3-1. Figure depicting the change in av erage and max angle as a function of bolus consistency. 0.0000 2.0000 4.0000 6.0000 8.0000 10.0000 12.0000 14.0000 16.0000 ThinThickDisplacement (mm) Average Displacement Max Displacement Figure 3-2. Figure depicting the change in average and max displacement as a function of bolus consistency.

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30 0.0000 20.0000 40.0000 60.0000 80.0000 100.0000 120.0000 140.0000 160.0000 180.0000 ThinThickVelocity (Displacement/Time) Average Velocity Max Velocity Figure 3-3. Figure depicting the change in average and max velocity as a function of bolus consistency. Case Studies Below the data output from the MATLAB hyoi d trajectory program is provided for a single subject with both a safe (P-A=1) and unsafe (P-A=8) swallow. Table 3-11. Order of swallow events and hyoid trajectory measurements for “safe swallow”. Swallow Event Frame No.Angle Displacement Velocity Onset Bolus Transit 1 0.157 1.279 42.641 Palatal onset 11 2.45 -0.154 34.900 Bolus at ramus 12 2.059 -0.609 15.144 UES opening 17 2.741 1.288 14.484 Max Laryngeal Closure 20 1.549 2.258 71.923 UES closing 27 0.220 5.028 17.711 Palatal offset 34 7.788 -2.136 32.096 Following are the figures depicting the trajec tory of the hyoid in terms of angle and in terms of displacement (Figures 3-4 through 3-9). Although the pattern of movement is similar, in the “safe and “unsafe” swallo ws, in the “unsafe” swallow the first three events (onset bolus transfer, palatal onset, a nd bolus head at ramus) have occurred within

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31 the first four frames, whereas in the “safe” sw allow the bolus doesn’t arrive at the ramus until the twelfth frame. Table 3-12. Order of swallow events and hyoid trajectory measurements for “unsafe swallow”. Swallow Event Frame No. Angle Displacement Velocity Onset Bolus Transit 1 0.306 2.165 72.177 Palatal onset 2 1.586 -0.252 80.583 Bolus head at ramus 4 0.790 -1.630 34.430 UES opening 11 4.772 2.721 105.261 Max Laryngeal Closure 18 7.567 6.332 18.484 UES closing 23 5.487 5.425 31.386 Palatal offset 26 7.500 0.923 44.175 Figure 3-4. Figure depicting the angle of the hyoid in degrees and th e relationship to the defined swallow events in the “safe sw allow”. Swallow events are labeled with asterisks.

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32 Figure 3-5. Figure depicting the angle of the hyoid in degrees and th e relationship to the defined swallow events in the “unsafe swallow”. Swallow events are labeled with asterisks. Figure 3-6. Figure depicting the displacem ent of the hyoid in millimeters and the relationship to the defined swallow even ts in the “safe swallow”. Swallow events are labeled with asterisks.

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33 Figure 3-7. Figure depicting the displacem ent of the hyoid in millimeters and the relationship to the defined swallow even ts in the “unsafe swallow”. Swallow events are labeled with asterisks. Figure 3-8. Figure depicting the hyoid tr ajectory in the “safe swallow”.

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34 Figure 3-9. Figure depicting the hyoid tr ajectory in the “unsafe swallow”. Below the data output from the MATLAB hyoi d trajectory program is provided for a participant with a shorter oral transit tim e because of little tongue pumping (TP=1) and another with a much larger amount of tongue pumping and an increased oral transit time (TP=7). P-A score was 1 for both swallows. Table 3-13. Order of swallow events and hyoid trajectory measurements for shorter swallow. Swallow Event Frame No. Angle DisplacementVelocity Onset Bolus Transit 1 1.328 -1.028 34.262 Bolus head ramus 10 4.5023 -3.100 15.206 Palatal onset 45 0.808 3.632 3.141 Max Laryngeal Closure 50 4.280 5.223 6.767 UES opening 51 3.569 6.479 41.869 UES closing 58 3.234 8.438 26.700 Palatal offset 65 4.986 1.314 26.966

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35 Table 3-14. Order of swallow events and hyoid trajectory measurements for longer swallow. Swallow Event Frame No.Angle DisplacementVelocity Onset Bolus Transit 1 2.173 0.811 27.029 Bolus head at ramus 71 2.460 1.851 42.338 Palatal onset 145 10.920 7.282 61.012 Max laryngeal Closure 147 15.765 7.719 13.113 UES opening 149 17.825 9.339 41.617 UES closing 156 17.154 7.485 51.887 Palatal Offset 165 8.851 8.856 22.010 Following are the figures depicting the trajec tory of the hyoid in terms of angle and in terms of displacement (Figures 3-10-3-15). There are great differences in the amount of movement of the hyoid, with much more extraneous movement of the hyoid observed in the swallow containing more tongue pumping. The order of the swallow events is the same in both swallows, but the distribution of the events throughout the length of time is quite different. Figure 3-10. Figure depicting the angle of the hyoid moveme nt and the relationship to the defined swallow events in the shorter swallow. Swallow events are labeled with asterisks.

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36 Figure 3-11. Figure depicting the angle of the hyoid moveme nt and the relationship to the defined swallow events in the longer swallow. Swallow events are labeled with asterisks. Figure 3-12. Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallow even ts in the shorter swallow. Swallow events are labeled with asterisks.

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37 Figure 3-13. Figure depicting the displacement of the hyoid in millimeters and the relationship to the defined swallow even ts in the longer swallow. Swallow events are labeled with asterisks. Figure 3-14. Figure depicting the hyoi d trajectory in the shorter swallow.

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38 Figure 3-15. Figure depicting the hyoid trajectory in the longer swallow.

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39 CHAPTER 4 DISCUSSION The current study assessed th e effects of bolus consistency on swallow timing and P-A score in persons with PD. The findings were mainly consistent with the hypotheses set forth, with the exception of some minor differences that will be discussed in greater detail below. The current study also presen ts exploratory data quantifying the motion of the hyoid bone in relation to measures of bol us transit and penetra tion/aspiration. These measures were obtained utilizing an innovative MATLAB program which provides information about angle, displacement, and th e order of events relative to hyoid motion. The following discusses the research findi ngs and their clinic al importance. Primary Aim Measures of Bolus Transit When measuring bolus transit, the primary dependent variables in cluded oral transit time, pharyngeal transit time, and number of tongue pumps. Both oral and pharyngeal transit time have been used to address bol us transit in varying populations (i.e., De Vincentiis et al., 2004; Han, Paik, & Park, 2001; Monte da Silva-Junior, Braga-Neto, Nobre e Souza, & Sales de Bruin, 2005; Nagaya et al., 1998; Robbins, Levine, Maser, Rosenbek, & Kempster, 1993). In the current study, a significant difference was found in oral transit time as a func tion of the thickness of the bolus, with oral transit time increasing with thicker boluses. These findi ngs are not surprising. Past research has found that thicker consistencies lead to greater oral transit times (Dantas et al., 1990), but

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40 this relationship had not been identified in the PD population, nor has the cause of the increased oral transit time been discussed. Increased oral transit times can be cause d by various factors, many of which are related to the motion of the t ongue. The presence of tongue pumping in persons with PD may not only affect the bolus movement from the anterior portion of the oral cavity to the posterior portion, but may also affect the stre ngth with which the bolus is propelled into the pharynx. Although the presen ce of tongue pumping, also refe rred to as festination of the tongue or lingual rocking, has been identified in persons with PD (i.e., Hunter et al., 1997; Leopold et al., 1996; Nagaya et al., 1998), quantifying the number of tongue pumps has never been completed to the re searcherÂ’s knowledge. This measure was selected as the most obvious characteristic of the oral phase of swallow in persons with PD, which was associated with an increase in oral transit time. Results identified not only the effect of the differing consistencies on oral transit time, but number of tongue pumps as a predic tor of increased oral transit, with a significant positive correlation found between number of tongue pumps and oral transit time. This significantly positive relationship was only identified in the pudding thick consistency. There was also a significan t difference between the number of tongue pumps in the thin versus th e pudding thick consistencies. The literature discussing the festinating tongue phenomenon states that th is process is caused by bradykinesia and rigidity of the tongue (Bushmann et al., 1989; Edwards, Quigley, & Pfeiffer, 1982). There is little explanation as to why the tongue pumping does not occur as frequently in thinner consistencies, or why there is no rela tionship between oral tr ansit time and tongue pumping in thinner consistencies.

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41 It can be hypothesized that the thinner boluses lack of resistance to flow may reduce the need for oral mani pulation, thus causing spillage in to the posterior portion of the oral cavity, and possibly the pharynx. Since those with PD have difficulty coordinating movements, as well as slowness a nd weakness of the oral musculature, it is possible that the bolus moves to the poster ior portion of the oral cavity before the structures are prepared to rece ive the bolus and trigger the phar yngeal swallow. It is for this reason that the relationship between t ongue pumping, pharyngeal transit time, and PA score was addressed. A significant relationship between tongue pumping and pharyngeal transit time was identified through Pearson r correlations, with pharyngeal transit time increasing as number of tongue pumps increased. This relationship provides insight into the relationship between the oral phase of swallo w and the pharyngeal phase. Even with this defined relationship, a significant difference in pharyngeal transit time between the two consistencies was not found. The fact that pharyngeal transit time did not change significantly as a functio n of consistency may be due to limitations of the study like small sample size and small bolus size, or may be due to the reflexive nature of the pharyngeal phase in comparison to the more voluntary nature of the oral phase of swallow; especially in this population who ofte n exhibit more impairment in voluntary than involuntary behaviors (Yamaguchi & Kabayashi, 1998). However, this does not explain the relationship between tongue pum ping and pharyngeal transit time. The fact that tongue pumping was associated with increased pha ryngeal transit time in the pudding thick consistency, provides further support for the consideration of the swallow mechanism as a more cohesive unit versus a mechanism cons isting of separate phases which in the end

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42 add up to a swallow. In addition, this data supports the case that the pharyngeal phase of swallow, although reflexive by nature (i.e., Huckabee et al., 2003; Martin et al., 2001; Martin & Sessle, 1993; Mosier et al., 1999), is also controlled or influenced somewhat by voluntary mechanisms (Wheeler & Sapienza, 2006) In the case of th is participant pool, it can be hypothesized that the dysfunction of the base of tongue may have reduced the pressure with which the bolus was propelle d down the pharyngeal cavity, which could in turn have had repercussions on pharyngeal transit times. In summary, the data supported the hypothe ses set forth by the investigators. It was hypothesized that both oral and pharyngeal transit times would increase with thicker consistencies versus thinner consistencies. Although the means were greater for both oral and pharyngeal transit as a function of bol us consistency, pharyngeal transit did not demonstrate significance. This finding also supported the hypothesi s that oral transit time would be increased to a greater degree across the cons istency condition. Lastly, it was hypothesized that the num ber of tongue pumps would increase significantly with thicker consistencies, as was found in the data. Measures of Penetration/Aspiration Past research has found that thicker consistencies are sa fer for persons to ingest than thinner consistencies because they reduce the possibilities of penetration and aspiration (Bulow, Olsson, & Ekberg, 2003; K uhlemeier et al., 2001). It is on this premise that diet modification recommenda tions (i.e., thickner for thin liquids, or modification to puree consistenc ies) have been based. A si gnificant difference was found between P-A score as a function of consiste ncy, with P-A score being higher (less safe) for thinner consistencies, s upporting one of the hypotheses se t forth. Interestingly, the hypothesis that there would be a significan t negative correlation between oral and

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43 pharyngeal transit times and P-A scale values for the thick and thin consistencies was not supported by the data in this study. Pearson r correlations did not show significant relationships between oral transit time, pharynge al transit time, and/or tongue pumps with P-A score. This is somewhat surprising gi ven the strong relationshi p identified in this study between consistency, increased oral tr ansit and the number of tongue pumps, as well as the strong relationship identified in prior research between thicker consistencies and penetration/aspiration of the bolus. Fu rther discussion on the variables which could have possibly contributed to this result are to follow in the discussion of the study’s limitations. Quality of Life It was hypothesized that persons with more impaired oral stages of swallow would report more impaired quality of life, but no significant relationships were found between swallowing quality of life and ot her dependent measures, including penetration/aspiration. This may be explai ned by the “anosognosi c” nature of persons with PD. This population is often considered to have decreased in sight into their own behaviors and medical severi ty (Starkstein et al., 1 996, Seltzer et al., 2001). Interestingly, the oldest part icipant reported the be st swallowing quality of life, although both the oral and pharyngeal phases of this pa rticipant’s swallow were no more or less impaired than most of the other participants. This apparent reduced reliability of patients with PD to recognize or quantify swallow impa irment is important to note clinically. This lack of insight may prove detrimental to health and safety in later stages of dysphagia. It is therefore the responsibility of th e clinician to judge a patient’s insight into their own disorder, be it through inte rview or more extensive neuropsychological testing, in order to make wise decisions involving management of dysphagia. These

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44 issues can have negative implications for co mpliance of dietary modifications or use of compensatory strategies, and/or may ne gatively influence therapy outcomes. Exploratory Study The hyoid bone is an essential member of the swallow mechanism. Together with the suprahyoid muscles, this bone moves s uperiorly and anterior ly raising the larynx which ultimately protects the airway during swallowing. Befo re the UF hyoid trajectory program was developed, there had been no way to quantify the movements of the hyoid and relate them to various swallow events, in an automated, time efficient manner. With this program, investigators are able to quantify the angle and displacements of hyoid motion during swallow. In the current expl oratory study, these measures were obtained and then compared to timing and penetration/ aspiration measures in order to identify any preliminary relationships between the hyoi d motion and factors relating to swallow timing and penetration/aspiration. In additi on, various swallow events were overlayed on the hyoid trajectory measurements in order to better identify and describe the factors contributing to a safe or unsafe swallow. Al so, the pilot data that was presented in the results section was obtained and compared to the preliminary data of healthy adults. These comparisons were made in order to id entify differences in the motion of the hyoid bone as a function of disease process, and thus describe factors which may be influencing swallow safety and timing in patients with PD compared to healthy adults. Comparison of the means of the various dependent measures acquired from the MATLAB program (i.e., average and max a ngle, average and max displacement, and average and max velocity) as a function of consistency showed increases in all the measures related to hyoid movement with increased bolus thickness, except average hyoid displacement. This is c onsistent with past research which has shown that with

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45 increased bolus thickness there is a greater activation of the s uprahyoid muscles as measured by sEMG (Dantas & Dodds, 1990; Ding et al., 2003). Preliminarily, it seems that there is a relationship between angle size and penetration/aspiration of the bolus, but not a relationship between displacement and penetration/aspiration of the bolus. Within the thin consistencies, the participant with the largest average angle presented with a very safe swallow, and the person with the smallest angle was among those with the leas t safe swallow. In addition, the latter participant presented with the smallest maximum angle size. This is especially interesting in light of data from healthy c ontrols (Wheeler et al ., 2006) which found that angle was the only measure (of the depe ndents described above) which was not significantly different from pers on to person. In other words it was the most consistent of the measures within healthy controls, yet in this population of pe rsons with PD there seems to be great variability in the degree of angle produced with each swallow. This increased variability may be consistent w ith decreased coordination of swallow and subsequent differences in swallow safety, specifically penetration/aspiration. A case study presenting evidence of decrea sed coordination of the oral-pharyngeal phases of swallow resulting in an unsafe swallow was introduced in the results section. In this case, one safe (P-A=1) and one unsaf e (P-A=8) swallow, within the same patient, was analyzed in order to compare hyoid traj ectory measures. It was observed that although the trajectory pattern it self was not much different between the two swallows and the order of the swallow events was no different, the speed with which the swallow events occurred was quite different. In th e “unsafe” swallow, the bolus arrived at the ramus of the mandible by the fourth frame, whereas in the “safe” swallow the bolus

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46 arrived at the mandible in the twelfth fr ame. One could hypothesize that in this population, faster is not better, in terms of swallowing functio n. In this single case, it seems that the discoordination of the swallo w mechanism may have led to a rushing of the swallow events, and subsequent aspira tion. The relationship among increased speed of bolus events, together with discoord ination of the swallow mechanism, and penetration/aspiration is disc oncerting in this population which often presents with decreased cough strength (Ert ekin et al., 2002; Hunter et al., 1997) and limited insight into their condition (S tarkstein et al., 1996, Seltzer et al., 2001; Kleinow et al., 2001). Also interesting, was the absence of a ny recognizable trend between displacement and angle measurement or displacement and penetration/aspiration of the bolus. These findings challenge past research which ha s defined both the supe rior and anterior excursion of the hyoid bone essential for swallow (i.e., Logemann, 1983). The current pilot data would suggest that perhaps the a ngle of the hyoid motion is more important for a safe swallow than the hyoid displacement in th e anterior or superior direction alone In terms of the thick consistencies, much variability is present in hyoid motion due to the increased amount of extraneous tongue movement associated with tongue pumping. Because the tongue and hyoid bone are attached, it makes sense that tongue movements would result in movements of th e hyoid bone as well. The importance of these movements and their effect on subse quent motion of the hyoid related to the pharyngeal swallow are yet to be identified. It is challenging to discuss these data as there is no obvious trend to th e tongue movement, but it is in teresting to note the close relationship between these two structures which are essentia l components of the swallow mechanism.

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47 Limitations and Strengths There are several limitations to the current study. Primarily, the present is a small n study whose goal is to identify areas for furthe r research and identify differences which are present in the oral and pharyngeal phases of swallow as a function of consistency in patients with PD. The nature of this small n study limits the generalizability of the study’s results. Also, th e population which was recrui ted for this study, although homogeneous in their clinical severity, may ha ve been too mildly impaired to show true effects of the dependent variab les on P-A score. The lack of pharyngeal dysphagia in this current participant pool, may have acted as a ceiling effect due to the fact that many of the patients presented with relatively “s afe” swallows, and most did not aspirate. Although this is true, the trends which were observed are useful for predicting changes which may occur in patients with PD who exhibit more severe dysphagia. A ceiling effect may also have been caused by the size of the bolus. The five cc. bolus may have been too small to truly tax the system and s how changes which are representative of real life swallow challenges. This being said, the current study is the first of its kind, studying timing and P-A score as a function of cons istency, in a well controlled population, while concurrently obtaining data which greater specifies hyoid f unction relative to these variables. The current study controlled for medication stat e, with testing one hour after medication dosage, and controlling also for clinical severity of sympto ms. Also, randomization of the bolus presentation controlled for the possi ble effects of fatigue. The presentation of these randomized boluses using cup and s poon, versus syringe, made for a closer simulation of the participants’ daily eating rou tines. Lastly, the rese archers controlled for other medical diagnoses, which could have affected swallow function, these included

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48 dementia (i.e., Amella, 2004; Dahlin, 2004; Ka lia, 2003), other neur ological conditions (i.e., Logemann, 1983), head and neck cancer (i .e., Pauloski et al., 2002), and certain respiratory conditions, including COPD and asthma (i.e., Good-Fratturelli, Curlee, & Holle, 2002). Implications for Future Research In terms of the primary aim of this study, there are many more questions to be answered relative to the changes which occur in the oral-pharyngeal phases of swallow as a function of consistency differences in pers ons with PD. Now that a possible difference has been determined between consistency and penetration/aspiration in PD, and a preliminary relationship between tongue pumping on bolus transit times has been identified, research should focus on more specifically defining the changes which are taking place. Manometry would help asse ss the pressure changes which may be occurring at the base of tongue, causing s ubsequent changes in the pharyngeal and possibly the oral phases of swallow. The e ffects of bolus consistency on the relationship between swallowing and breathing in patients wi th PD is also an interesting question, especially due to the respiratory changes which often occur in this population, and the presence of dysphagia which had been descri bed in populations who exhibit respiratory compromise (i.e., Good-Fratturelli et al., 2002). Lastly, including pa rticipants with PD who exhibit more impairment of the pharyngeal swallow, coupled with the use of a larger bolus may help assess more specif ically the safety issues, particularly P-A score, of this population with high risk of death sec ondary to aspiration pneumonia. Implications for Swallow Intervention There are more questions than there are answers concerning swallow intervention. Even today, clinicians will limit patients PO in take or modify their diets long before it is

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49 necessary. This is driven mainly by a pauc ity of literature desc ribing the physiology of swallow secondary to variable s like consistency and compen sation strategies, in addition to questions related to aspira tion; its effects and repercussi ons. It is the hope of the investigator that through this and future re search, the many remaining questions may be slowly addressed, and the quality and length of life in persons with PD and other similar disorders may be enhanced due to bette r management of alimentary issues.

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APPENDIX A UNIFIED PARKINSONÂ’S DISEASE RATING SCALE (UPDRS)

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APPENDIX B THE SWAL-QOL SURVEY

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74 BIOGRAPHICAL SKETCH Michelle Troche graduated with her Bachelor of Arts degree in communication sciences and disorders and linguistics from the University of Florida in 2004. She graduated summa cum laude and also receiv ed minors in teaching English as a second language (TESL) and gerontology. She will comp lete the requirements for the Master of Arts degree in speech pathology at the Univer sity of Florida as well. After graduation, Michelle plans on pursuing a doctoral degree in speech pathology under the mentorship of Christine Sapienza, specializ ing in motor speech disorders.